It’s the start of the school year, and your 12-year-old patient who is entering 7th grade comes in for his annual checkup. His parent mentions the school needs some sort of letter because the boy’s Tdap vaccine was never given.
You scratch your head, wondering how this fell through the cracks, as children in your New Jersey practice cannot follow an alternative schedule. As you pull up the chart, you are immediately reminded of an event years ago: After receiving the 4th dose of DTaP as a toddler, this child experienced generalized hives, swelling of the lips, and difficulty breathing. The symptoms started 10 minutes after receiving his vaccine. He was treated for anaphylaxis in the office and fully recovered.
You have very few patients who require medical exemptions, so you set to work determining if this child should be exempt, and if so, what needs to be written and where should it be sent.
What is considered a medically indicated exemption?
While there is a changing landscape of exemptions for schools, every state permits school attendance without vaccination for medically indicated reasons. A significant adverse reaction or a known allergy to a vaccine component, even if the person has never received the vaccine, is a contraindication to receiving a particular vaccine, and would, therefore, require an exemption. A contraindication is a reason not to get a vaccine. Related to this, a precaution is a reason to consider the relative risks and benefits, which may vary by person or situation. In some cases, a precaution may necessitate delaying a vaccine for a short period, whereas in other situations, it may cause a prolonged or indefinite delay.
Certain health conditions that will persist throughout the patient’s life may require a medical exemption. For example, someone who has had a heart transplant and requires ongoing immune suppression may never be able to receive live, weakened viral vaccines, though they can continue to receive inactivated vaccines. The Centers for Disease Control and Prevention (CDC) maintains a list of contraindications and precautions that can be referenced for each vaccine.
In the scenario above, a previous significant adverse reaction to a vaccine or its components is a contraindication to receiving any additional doses of that vaccine. In the case of DTaP, it is impossible to determine which component caused the reaction, so the patient cannot receive any additional doses of DT, Tdap or Td in the future.
Can a child have a temporary medical contraindication?
Some people may have a time-limited contraindication to certain vaccines. While immunosuppression due to organ transplant will be lifelong, immunosuppression to treat cancer may be time limited. Indeed, many patients can resume vaccinations after completing their treatment. In cases among children, providers may have to write exemption letters for one to two years while a child is undergoing therapy for leukemia, but the child can resume the vaccination schedule in consultation with the child’s oncologist thereafter.
At times, patients may have specific time-limited exemptions. For example, children who receive intravenous immunoglobulin (IVIG) for treatment of Kawasaki disease cannot receive MMR or varicella vaccines for 11 months due to interference with the immune response. Those who received convalescent plasma to treat COVID-19, should not get MMR or varicella vaccines for seven months, and those who receive rabies immunoglobulin only need to wait four months before getting MMR or varicella vaccines. Medical exemption letters should detail these time periods so that the school can anticipate when the child will be able to be vaccinated.
About half of states have laws distinguishing between temporary and permanent medical contraindications, and in these cases, the details of the law dictate how an exemption letter should be written.
In the above scenario, the provider checks the New Jersey requirements and finds that they need to indicate the period of time for the exemption. This child will require a permanent exemption, which should be included in the documentation.
What are best practices for writing these letters?
Some states may have a suggested form, while others may require the provider to write an individualized letter. At a minimum, letters should include the patient's name and date of birth, the name of the vaccine(s) the exemption applies to, a clear statement that the vaccine is not recommended due to medical reasons, and a clinician's signature, date, and license information. Each state outlines who can sign a medical exemption letter, so the provider should be sure they are appropriately licensed to do so. The letter should also specify the duration of the exemption, if applicable, and any relevant medical conditions.
Because laws around exemptions change frequently, providers should consult the latest guidance from their state’s department of health. At a minimum, the paperwork will need to be submitted to the school, and a copy should be kept in the child’s medical record. Some states also require submission to the department of health.
The provider in this scenario finds that New Jersey maintains a PDF form that can be used to ensure that all necessary information is transmitted.
Wrap-up
The number of children who truly cannot receive immunizations due to a medical condition is small. However, ensuring that exemptions are granted appropriately will help keep them from affecting overall vaccination rates. Also, remind families that while the exemption allows their child to attend school, outbreaks may require them to act differently than other families because of the child’s vaccination status. This way, they will be prepared in advance of any event, which will make working with them during such a situation easier.
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It’s the start of the school year, and your 12-year-old patient who is entering 7th grade comes in for his annual checkup. His parent mentions the school needs some sort of letter because the boy’s Tdap vaccine was never given.
You scratch your head, wondering how this fell through the cracks, as children in your New Jersey practice cannot follow an alternative schedule. As you pull up the chart, you are immediately reminded of an event years ago: After receiving the 4th dose of DTaP as a toddler, this child experienced generalized hives, swelling of the lips, and difficulty breathing. The symptoms started 10 minutes after receiving his vaccine. He was treated for anaphylaxis in the office and fully recovered.
You have very few patients who require medical exemptions, so you set to work determining if this child should be exempt, and if so, what needs to be written and where should it be sent.
What is considered a medically indicated exemption?
While there is a changing landscape of exemptions for schools, every state permits school attendance without vaccination for medically indicated reasons. A significant adverse reaction or a known allergy to a vaccine component, even if the person has never received the vaccine, is a contraindication to receiving a particular vaccine, and would, therefore, require an exemption. A contraindication is a reason not to get a vaccine. Related to this, a precaution is a reason to consider the relative risks and benefits, which may vary by person or situation. In some cases, a precaution may necessitate delaying a vaccine for a short period, whereas in other situations, it may cause a prolonged or indefinite delay.
Certain health conditions that will persist throughout the patient’s life may require a medical exemption. For example, someone who has had a heart transplant and requires ongoing immune suppression may never be able to receive live, weakened viral vaccines, though they can continue to receive inactivated vaccines. The Centers for Disease Control and Prevention (CDC) maintains a list of contraindications and precautions that can be referenced for each vaccine.
In the scenario above, a previous significant adverse reaction to a vaccine or its components is a contraindication to receiving any additional doses of that vaccine. In the case of DTaP, it is impossible to determine which component caused the reaction, so the patient cannot receive any additional doses of DT, Tdap or Td in the future.
Can a child have a temporary medical contraindication?
Some people may have a time-limited contraindication to certain vaccines. While immunosuppression due to organ transplant will be lifelong, immunosuppression to treat cancer may be time limited. Indeed, many patients can resume vaccinations after completing their treatment. In cases among children, providers may have to write exemption letters for one to two years while a child is undergoing therapy for leukemia, but the child can resume the vaccination schedule in consultation with the child’s oncologist thereafter.
At times, patients may have specific time-limited exemptions. For example, children who receive intravenous immunoglobulin (IVIG) for treatment of Kawasaki disease cannot receive MMR or varicella vaccines for 11 months due to interference with the immune response. Those who received convalescent plasma to treat COVID-19, should not get MMR or varicella vaccines for seven months, and those who receive rabies immunoglobulin only need to wait four months before getting MMR or varicella vaccines. Medical exemption letters should detail these time periods so that the school can anticipate when the child will be able to be vaccinated.
About half of states have laws distinguishing between temporary and permanent medical contraindications, and in these cases, the details of the law dictate how an exemption letter should be written.
In the above scenario, the provider checks the New Jersey requirements and finds that they need to indicate the period of time for the exemption. This child will require a permanent exemption, which should be included in the documentation.
What are best practices for writing these letters?
Some states may have a suggested form, while others may require the provider to write an individualized letter. At a minimum, letters should include the patient's name and date of birth, the name of the vaccine(s) the exemption applies to, a clear statement that the vaccine is not recommended due to medical reasons, and a clinician's signature, date, and license information. Each state outlines who can sign a medical exemption letter, so the provider should be sure they are appropriately licensed to do so. The letter should also specify the duration of the exemption, if applicable, and any relevant medical conditions.
Because laws around exemptions change frequently, providers should consult the latest guidance from their state’s department of health. At a minimum, the paperwork will need to be submitted to the school, and a copy should be kept in the child’s medical record. Some states also require submission to the department of health.
The provider in this scenario finds that New Jersey maintains a PDF form that can be used to ensure that all necessary information is transmitted.
Wrap-up
The number of children who truly cannot receive immunizations due to a medical condition is small. However, ensuring that exemptions are granted appropriately will help keep them from affecting overall vaccination rates. Also, remind families that while the exemption allows their child to attend school, outbreaks may require them to act differently than other families because of the child’s vaccination status. This way, they will be prepared in advance of any event, which will make working with them during such a situation easier.