1. State Immunization Requirements for Juveniles in Detention Facilities
Megan Lindley1, Gail Horlick1, Abigail Shefer1, Fred Shaw2, Margaret Gorji3
1 National Immunization Program, CDC
2 Public Health Law Program, CDC
3 Warner, Mayoue, Bates & Nolen, PC
March 8, 2007
The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy.

2. Background
Laws requiring immunizations for school entry have been shown to improve child & adolescent vaccination coverage in elementary and middle schools.
Little is known about the use of immunization laws in other settings.

3. Objective
Determine status of laws, regulations, and other legal requirements relating to immunization in juvenile detention facilities

4. Methods
Legal analysts in CDC’s Public Health Law Program collected statutes and regulations from all 50 states and D.C.
Lexis-Nexis
Public web-based databases
Data collected September 2004 – June 2005
Legal counsel from each state given opportunity to comment on accuracy, completeness and interpretation of findings

5. Study Questions
Assessment: Is the facility required to assess immunization status or screen for any vaccine-preventable disease (VPD)?
Administration:
Offer: Is the facility required to offer or make available any vaccine to any resident?
Ensure: Is the facility required to provide, arrange for or make certain that any resident has been vaccinated against any VPD?
Exemptions: medical, religious, philosophical
We looked at laws pertaining to immunization assessment and administration. To determine if state had an assessment law, we asked…
Administration laws were divided into offer and ensure laws. Offer law = vaccination is optional, ensure law = vaccination is mandatory unless no consent or exemption

6. Results: Correctional Facilities
Assess
Administer
Ensure
Any immunizations
13 (25%)
18 (35%)
Hepatitis B 1* 1
1/1
Routinely rec.
(all inmates) 9 3
3/3
(juvenile detention) 5
16**
16/16
Point out that ALL laws for this population are ensure laws, meaning that vaccination is mandatory without a specified exemption or refusal on the part of the patient. One of ‘all inmates laws’ was specific to ‘adult correctional facilities’
* If charged with certain crimes, including sex crimes and drug offenses **In 13 states, the law does not refer specifically to juvenile detention facilities, but is written in such a way that it could be interpreted as applying to such facilities.

7. Results: Exemptions n (%)* Any exemption 8 (50%) Medical exemption
Religious exemption
5 (31%)
Philosophical exemption
1 (6%)
Exemptions codified in law…obviously all states have a de facto medical exemption. NB = usually parent or legal guardian signs affidavit of belief, process of obtaining exemptions may differ for children in justice system.
*Proportion among states with “ensure” laws for juveniles, n=16

8. Timeline for Compliance
On admission
3 (19%)
Within 7 days of admission
1 (6%)
Within 14 days of admission
2 (13%)
Within 30 days of admission
5 (31%)
Not specified
6 (38%)
This does add up to more than 100% due to rounding, and because one state has two separate laws – a specific requirement for hepatitis B vaccination on admission, and a general up-to-date requirement with no specified timeframe.
*Proportion among states with “ensure” laws for juveniles, n=16

9. Variation in State Requirements
Legal definitions of facilities vary by state
Terminology, ages of ‘juveniles’ (<16, 18, 21)
Departmental responsibility for oversight varies by state
Laws under authority of Corrections/Justice Department, Child/Family Services, Social Services, Health Department, etc.
Broad or unclear statutory language can create difficulties in interpretation
State counsel in different jurisdictions had varying interpretations of laws

10. Interpretation of Laws
Based on location of statute in code; legal definitions of facilities, occupants
Location: “Family and Youth Services and Juvenile Justice” or “Placement and Detention”
Facilities: “authorized to use locked doors…to prevent children from leaving” or “24-hour living setting [for unrelated] children” or having “legal custody” of children
Occupants: children “adjudicated as delinquent” or “who have committed an offense that is only committable by children” or “habitually truant”

11. Example
“ Ind. Admin. Code tit. 470, r requires that the child caring institution […] ensures that each child has received immunizations […] all children must be immunized against routine childhood disease. ‘Child caring institutions’ are defined in Ind. Admin. Code tit. 470, r as place engaged in (among other things) receiving and caring for dependent children, children in need of services, or delinquent children.”
Not applicable to juvenile detention centers (response from state counsel)
For example, here is text from the Indiana Administrative Code pertaining to ‘child caring institutions’. However, counsel from at least 5 other states felt that this interpretation of similar general requirements for child caring facilities was appropriate.

12. Use of School Entry Laws
Two states apply school entry requirements to children in juvenile justice system
Texas: Law explicitly states that vaccines required for school entry are also “required for…children admitted, detained, or committed in Texas Department of Criminal Justice…and Texas Youth Commission facilities”.
South Dakota: Program Administrator for Correctional Health Services considers juvenile detention facilities to be certified schools, subject to school entry laws
Note contrast: One actually has a written law stating that these requirements apply to juvenile detention centers, one is a matter of interpretation.

13. Conclusions
Less than half the states have laws requiring vaccination of incarcerated juveniles
Few explicitly directed toward detention facilities
State laws vary in terms of who is covered, responsibility for enforcement, and interpretation

14. Implications
State by state variation may preclude or complicate development of consistent national policy or model legislation
Advocates for vaccination of children in juvenile detention facilities should:
promote awareness of existing state laws
understand how laws are interpreted in their jurisdiction

15. Questions? Megan C. Lindley, MPH
Contractor, McKing Consulting Corporation
National Center for Immunization & Respiratory Diseases (proposed)