NEBRASKA ADMINISTRATIVE CODE
TITLE 173 – CONTROL OF COMMUNICABLE DISEASE
CHAPTER 3 – SCHOOL HEALTH, COMMUNICABLE DISEASE CONTROL, AND PHYSICAL EXAMINATION AND IMMUNIZATION STANDARDS
| Page | ||
| 3-001 | DEFINITIONS | 2 |
| 3-002 | EXCLUSION FROM SCHOOL | 2 |
| 3-003 | REPORTING | 2 |
| 3-004 | DURATION OF EXCLUSION PERIOD | 2 |
| 3-005 | EXCLUSION OF HEALTH CONTACTS | 3 |
| 3-006 | PHYSICAL EXAMINATION STANDARDS | 3 |
| 3-007 | 3 | |
| 3-008 | 5 | |
| 3-09 | MEDICAL AND RELIGIOUS EXEMPTION | |
| 3-10 | PROVISIONAL ENROLLMENT | 5 |
| 3-010 | TIME OF COMPLIANCE | 7 |
| 3-011 | REPORTING REQUIREMENTS | 7 |
| ATTACHMENT 1 – CONTAGIOUS AND INFECTIOUS DISEASE CHART | 11 | |
| TITLE 173 – CONTROL OF COMMUNICABLE DISEASE | ||
| CHAPTER 3 – SCHOOL HEALTH, COMMUNICABLE DISEASE CONTROL, AND PHYSICAL EXAMINATION AND IMMUNIZATION STANDARDS | ||
3-001 DEFINITIONS: For purposes of these regulations:
Child or children means any student or students enrolled in a public or private elementary or secondary school system in Nebraska.
Department means the Department of Health and Human Services.
Reportable communicable disease means those diseases which are required by law to be reported pursuant to 173 NAC 1-003 .
3-002 EXCLUSION FROM SCHOOL: Children showing any signs or symptoms of a contagious or infectious disease are required by law to be sent to their homes immediately, or as soon as safe and proper conveyance can be found.
Teachers are encouraged to observe each child carefully for signs of illness each time the child returns to school. This is particularly important when epidemic diseases are known to be present in the community.
The presence of one or more of the following signs or symptoms should make the teacher suspect a communicable disease:
Fever, flushed face, headache, aches in muscles or joints, unexplained tiredness or listlessness, loss of appetite, stomach ache, nausea or vomiting, diarrhea, convulsions, sore throat, nasal congestion or discharge, unexplained skin eruption, sore or inflamed eyes.
3-003 REPORTING: When a child is sent home because of a suspected reportable communicable disease, the law requires the teacher to report the circumstances to the board of health, proper school authority, school board or board of education without delay.
The secretary of the county board of health is the county clerk or superintendent of public instruction; in cities or villages it is the chief of police or marshal. They are usually the persons designated to receive such reports in areas not served by an approved, full-time public health service. In the latter areas, the director of the local health department receives them.
3-004 DURATION OF EXCLUSION PERIOD: Children excluded for a confirmed communicable disease should not be allowed to return to school until the minimum isolation period has elapsed, and all signs or symptoms of illness have disappeared. Minimum isolation periods are shown in the table on Attachment 1, Contagious and Infectious Disease Chart, which is attached to 173 NAC 3 and incorporated by this reference. School boards and boards of education may observe these periods, or adopt and enforce their own exclusion regulations which may not be shorter or less restrictive than those contained in 173 NAC 3.
3-005 EXCLUSION OF HEALTH CONTACTS: With a few exceptions (which are shown in the table on Attachment 1) there are no restrictions placed upon the health contacts of communicable diseases by these regulations; consequently, they may attend school unless the local health department, board of health, school board or board of education has adopted rules and regulations to the contrary. If school officials consider exclusion of health contacts necessary, it is suggested that whenever possible this be confined to the latter portion of the incubation period and enforced only for those children who are not known to be immune.
3-006 PHYSICAL EXAMINATION STANDARDS: A printed or typewritten form signed by a licensed physician, physician assistant, or nurse practitioner indicating that a physical examination was administered on a specific date within the previous six-month period on a specifically named individual constitutes sufficient evidence of a physical examination by a qualified physician within six months prior to the entrance of a child into the beginner grade and the seventh grade. A physical exam is also required in the case of a transfer from out of state to any other grade of the local school. As a substitute for such evidence of a physical, an objection in writing to a physical examination of such child signed and dated by a parent or guardian of such child may be submitted to the local school.
3-007 IMMUNIZATION STANDARDS: Each student must be protected by immunization against the following diseases, unless otherwise exempted from this requirement under the provisions of 173 NAC 3-009:
3-007.01 For the purposes of complying with the requirement of immunization against the diseases listed above:
3-007.01A Students 2 - 5 years of age enrolled in a school-based program not licensed as a child care provider are considered to be immunized if they have received –
3 doses of hepatitis B vaccine,
4 doses of DTaP, DTP, or DT, vaccine,
3 doses of polio vaccine,
1 dose of MMR vaccine given no earlier than 4 days before the first birthday,
3 doses of hib vaccine or 1 dose of hib vaccine given at or after 15 months of age, and
1 dose of varicella vaccine.
3-007.01B Students enrolling for the first time (kindergarten or 1 st grade depending on the school district's entering grade), enrolling in 7 th grade, and all transfer students from outside the state regardless of the grade they are entering are considered immunized if they have received –
3 doses DTaP, DTP, DT, or Td vaccine with at least 1 dose given no earlier than 4 days before 4 years of age,
3 doses of polio vaccine,
2 doses of MMR vaccine with the first dose given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days, 3 doses of pediatric hepatitis B vaccine, or, if the alternate hepatitis B vaccination schedule is used, 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age, and
The number of doses for varicella is dependent on the age of the child - 1 dose of varicella vaccine before the 13 th birthday; or 2 doses of varicella vaccine administered at least 28 days apart if the first dose was given on or after the 13 th birthday.
Varicella immunization is being phased in beginning with the 2004-2005 school year. Varicella will be included as a required vaccine in each subsequent grade as the child progresses from kindergarten (1 st grade) or 7 th grade through the remaining grades.
3-007.01C All other students are considered immunized if they have received –
3 doses of DTaP, DTP, DT, or Td vaccine,
3 doses of polio vaccine, and
2 doses of MMR vaccine given no earlier than 4 days before the first birthday and the 2 doses separated by at least 28 days.
Beginning July 1, 2005, all students grades K-12 will be required to present evidence of 3 doses of pediatric hepatitis B vaccine, or, if the alternate hepatitis B vaccination schedule is used, 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age.
3-008 REQUIRED EVIDENCE OF IMMUNIZATION
3-008.01 For purposes of compliance with the immunization requirement, the board of education or school board or other governing authority, must require the presentation of an immunization history containing the name of the vaccine, the month and year of administration (the month, day, and year for MMR vaccine and varicella vaccine), the name of the health practitioner, the agency where the immunization was obtained, and the signature of physician, parent, guardian, or of such other person maintaining the immunization history of the student, verifying that the student has received these vaccines.
3-008.02 Laboratory evidence of circulating antibodies for measles, mumps, or rubella constitutes evidence of immunity against those diseases provided the following information is supplied: name of laboratory, date of test, name of test, test result, signature of laboratory technician performing the test or of the laboratory director, and date of signature. For purposes of compliance with this rule, clinical history of measles, mumps, or rubella without laboratory or epidemiologic confirmation does not constitute evidence of immunity.
3-008.03 Epidemiologic confirmation of a diagnosis means that the clinical history of measles, mumps, or rubella is corroborated by association with laboratory proven case(s) and that such epidemiologic case(s) have been reported to and counted by the Department.
3-008.04 A documented history of varicella disease from a parent or health care provider with the year of infection constitutes evidence of immunity to varicella. The documentation must include one of the following –
1. Signature of the parent or legal guardian and the date (year) of the child's varicella illness, or
2. Signature of a health care provider and the date (year) of the child's varicella illness, or
3. Laboratory evidence of a child's varicella immunity.
3-009 MEDICAL AND RELIGIOUS EXEMPTION; PROVISIONAL ENROLLMENT: Each student must be protected against the diseases listed using the standards described in 173 NAC 3-007 and submit evidence of immunization as described in 173 NAC 3-008. Any student who does not comply with these requirements must not be permitted to enroll in school, except as provided in 173 NAC 3-009.01 through 3-009.03.
3-009.01 Immunization is not required for a student's enrollment in any school in this state if he or she submits to the admitting official either of the following:
3-009.01A A statement signed by a physician, physician assistant, or nurse practitioner stating that, in the health care provider's opinion, the specified immunization(s) required would be injurious to the health and well-being of the student or any member of the student's family or household; or
3-009.01B A notarized affidavit signed by the student or, if he or she is a minor, by a legally authorized representative of the student, stating that the immunization conflicts with the tenets and practice of a recognized religious denomination of which the student is an adherent or member or that immunization conflicts with the personal and sincerely followed religious beliefs of the student.
3-009.02 A student may be provisionally enrolled in a school in Nebraska if he or she has begun the immunizations against the specified diseases prior to enrollment and continues the necessary immunizations as rapidly as is medically feasible. For purposes of complying with these requirements:
3-009.02A A student is considered to have begun immunizations against polio, diphtheria, tetanus, pertussis, hepatitis B, measles, mumps, and rubella if he or she has had at least one dose of DTaP/DTP/DT/Td, one dose of hepatitis B, one dose of either trivalent OPV or one dose of IPV, either one dose of the combined measles, mumps, and rubella vaccine or one dose of each vaccine for measles, mumps, and rubella, and one dose of varicella vaccine if the child is over 13 years of age.
3-009.02B Continuation of necessary immunizations as rapidly as is medically feasible must be documented by a written statement from the student's immunization provider which shows the scheduled dates to complete the required immunization series. Failure to receive the necessary immunizations as rapidly as is medically feasible will result in exclusion of the student from attending school until either documentation of immunization or a medical statement or religious affidavit is provided to the school. The time interval for the completion of the required immunization series must not exceed nine months.
3-009.03 A student may also be provisionally enrolled in a school in Nebraska if he or she is the child or legal ward of an officer or enlisted person, or the child or legal ward of the spouse of such officer or enlisted person on active duty in any branch of the military services of the United States, and said student is enrolling in a Nebraska school following residence in another state or in a foreign country.
3-009.03A As a condition for the provisional enrollment of a student under this Section, a parent or adult legal guardian of the student must provide the school with a signed written statement certifying that the student has completed the course of immunizations required by 173 NAC 3-007.
3-009.03B The provisional enrollment of a student qualified for such enrollment under 173 NAC 3-009.03 must not continue beyond 60 days from the date of such enrollment. At such time, the school must be provided, with regard to said student, written evidence of compliance with 173 NAC 3-007. The student must not be permitted to continue in school after such date until evidence of compliance is provided.
3-010 TIME OF COMPLIANCE: Each student must present documentation as outlined in 173 NAC 3-008 and 3-009 prior to enrollment.
3-011 REPORTING REQUIREMENTS: A report to the Department summarizing immunization status will be required by November 15 of each year from the board of education or school board of each school district, or other governing authority of the school. The report will include the following information regarding those entering school for the first time (kindergarten or 1 st grade), those entering the 7th grade, and all transfer students from outside the state (excluding the entering and 7th grades):
3-011.01 For children in the entering grade (kindergarten or 1 st grade depending on the school district's entering grade)–
1. The total number of students enrolled.
2. The total number of students with an exemption on file or who are in the process of completing immunizations.
3. Diphtheria, tetanus, and pertussis (DTP/DTaP/DT/Td) –
a. The number of students with 3 or more doses of DTP/DTaP/DT/Td, with at least one dose given at or after 4 years of age.
b. The number of students with medical exemptions on file for diphtheria, tetanus, and pertussis.
c. The number of students with religious exemptions on file for diphtheria, tetanus, and pertussis.
d. The number of students provisionally enrolled.
4. Polio (IPV/OPV) –
a. The number of students with 3 or more doses of polio vaccine.
b. The number of students with medical exemptions on file for polio.
c. The number of students with religious exemptions on file for polio.
d. The number of students provisionally enrolled.
5. Measles, mumps, and rubella (MMR) –
a. The number of students with 2 doses of MMR with the first dose given no earlier than 4 days before the 1 st birthday and the 2 doses separated by at least 28 days.
b. The number of students presenting laboratory evidence of circulating antibodies or epidemiologic confirmation of measles, mumps, and rubella.
c. The number of students with medical exemptions on file for MMR.
d. The number of students with religious exemptions on file for MMR.
e. The number of students provisionally enrolled.
6. Hepatitis B –
a. The number of students with 3 doses of pediatric hepatitis B, or, if the alternate hepatitis B vaccination schedule is used, the number of students with 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age.
b. The number of students with medical exemptions on file for hepatitis B.
c. The number of students with religious exemptions on file for hepatitis B.
d. The number of students provisionally enrolled.
7. Varicella –
a. The number of students with 1 dose of varicella vaccine.
b. The number of students with documented history of disease.
c. The number of students with medical exemptions on file for varicella.
d. The number of students with religious exemptions on file for varicella.
e. The number of students provisionally enrolled.
3-011.02 For children entering 7th grade –
1. The total number of students enrolled.
2. The total number of students with an exemption on file or who are in the process of completing immunizations.
3. Measles, mumps, and rubella (MMR) –
a. The number of students with 2 doses of MMR, with the first dose given no earlier than 4 days before the 1 st birthday and the 2 doses separated by at least 28 days.
b. The number of students presenting laboratory evidence of circulating antibodies or epidemiologic confirmation of measles, mumps, and rubella.
c. The number of students with medical exemptions on file for MMR.
d. The number of students with religious exemptions on file for MMR.
e. The number of students provisionally enrolled.
4. Hepatitis B –
a. The number of students with 3 doses of pediatric hepatitis B, or, if the alternate hepatitis B vaccination schedule is used, the number of students with 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age.
b. The number of students with medical exemptions on file for hepatitis B.
c. The number of students with religious exemptions on file for hepatitis B.
d. The number of students provisionally enrolled.
5. Beginning July 1, 2004, and thereafter, Varicella –
a. The number of students with the appropriate dose(s) of varicella vaccine (1 dose if given before the 13 th birthday or 2 doses if the first dose was given on or after the 13 th birthday and separated by 28 days).
b. The number of students with documented history of disease.
c. The number of students with medical exemptions on file for varicella.
d. The number of students with religious exemptions on file for varicella.
e. The number of students provisionally enrolled.
3-011.03 For transfer students from outside the state –
1. The total number of students enrolled.
2. The total number of students with an exemption on file or who are in the process of completing immunizations.
3. Measles, mumps, and rubella (MMR) –
a. The number of students with 2 doses of MMR, with the first dose given no earlier than 4 days before the 1 st birthday and the 2 doses separated by at least 28 days.
b. The number of students presenting laboratory evidence of circulating antibodies or epidemiologic confirmation of measles, mumps, and rubella.
c. The number of students with medical exemptions on file for MMR.
d. The number of students with religious exemptions on file for MMR.
e. The number of students provisionally enrolled.
4. Hepatitis B –
a. The number of students with 3 doses of pediatric hepatitis B, or, if the alternate hepatitis B vaccination schedule is used, the number of students with 2 doses of a licensed adult hepatitis B vaccine specified for adolescents 11-15 years of age.
b. The number of students with medical exemptions on file for hepatitis B.
c. The number of students with religious exemptions on file for hepatitis B.
d. The number of students provisionally enrolled.
5. Varicella –
a. The number of students with the appropriate dose(s) of varicella vaccine (1 dose if given before the 13 th birthday or 2 doses if the first dose was given on or after the 13 th birthday and separated by 28 days).
b. The number of students with documented history of disease.
c. The number of students with medical exemptions on file for varicella.
d. The number of students with religious exemptions on file for varicella.
e. The number of students provisionally enrolled.
3-011.04 The abbreviated reporting requirements for entering 7th graders and transferring students does not exempt them from meeting the immunization standards outlined in 173 NAC 3-007.01B.
| DISEASE | INCUBATION PERIOD* | SYMPTOMS OF ILLNESS | INFECTION PERIOD | MINIMUM ISOLATION PERIODS AND CONTROL MEASURES |
| Chickenpox | 2 to 3 weeks | Fever, skin eruption begins as red spots that become small blisters (vesicles) and then scab over. | For up to 5 days before eruption until no more than 6 days after appearance of vesicles. | Exclude for at least 5 days after the eruption first appears or until vesicles become dry; avoid contact with susceptibles. No exclusion of contacts. Alert parents of immune-suppressed child(ren) of possible exposure. |
| Conjunctivitis (Pink Eye) | 24-72 hours | Redness of white of eye, tearing, discharge of pus. | During active phase of illness characterized by tearing and discharge. | Exclude symptomatic cases. Urge medical care. May return when eye is normal in appearance or with documentation from physician that child is no longer infectious. No exclusion of contacts. |
| Coryza (Common Cold) | 12 to 72 hours | Nasal discharge, soreness of throat. | One day before symptoms and usually continuing for about 5 days. | Exclusion unnecessary. No exclusion of contacts. |
| Diphtheria | 2 to 5 days | Fever, sore throat, often gray membrane in nose or throat. | Usually 2 weeks or less. | Exclude cases. Return with a documented physician approval. Exclude inadequately immunized close contacts as deemed appropriate by school officials following investigation by the local and/or Nebraska Department of Health and Human Services. Report immediately by telephone all cases to local and/or state health departments. |
| Enterobiasis (Pinworm, Thread-worm, Seatworm) | Life cycle about 3 to 6 weeks | Irritation around anal region. Visible in stool. | As long as eggs are being laid; usually 2 weeks. | Exclude until treated as documented by physician. No exclusion of contacts. Careful handwashing essential. |
| Fifth Disease | Estimated at 6-14 days | Minimal symptoms with intense red "slapped cheek". Appearing rash; lace-like rash on body. | Unknown. | Exclude until fever and malaise are gone. May return with rash with documented physician approval. No exclusion of contacts; however, alert any students or staff who are pregnant, have chronic hemolytic anemia or immunodeficiency to consult their physician. |
| Hepatitis A | 15-50 days, average 28-30 days | Fever, nausea, loss of appetite, abdominal discomfort and jaundice. | Two weeks before jaundice until about 7 days after onset of jaundice. | Exclude for no less than 7 days after onset of jaundice. Return with documented physician approval. No exclusion of contacts. Immune globulin (IG) prevents disease if given within two weeks of exposure. IG to family contacts only. Careful handwashing essential. |
| Herpes | 2-12 days | Onset as clear vesicle, later purulent. Following rupture, scabs and in 1-2 weeks, heals. Commonly about lips | For a few weeks after | Exclusion unnecessary. No exclusion of contacts. Avoid contact with immunesuppressed or eczematous persons. Good personal hygiene, avoid sharing toilet articles. |
| Impetigo | 4-10 days | Running, open sores with slight marginal redness. | As long as lesions | Exclude until brought under treatment as documented by physician. No exclusion of contacts. Good personal hygiene is essential. Avoid common use of toilet articles. |
| Influenza | 24-72 hour | Fever and chills, often back or leg aches, sore throat, | A brief period before | Exclude for duration of illness. No exclusion of contacts. |
| Meningitis | Varies depending | Sudden onset of fever. Intense headache, nausea, often vomiting. Stiff neck, delirium or petechial rash, shock. | Variable. | Exclude for duration of illness. Return with documented physician approval. No exclusion of contacts. Chemoprophylaxis appropriate for |
| Measles | 10-14 days | Begins like a cold; fever, blotchy rash, red eyes, hacking frequent cough. | 3-4 days before rash | Exclude for duration of illness and for no less than 4 days after onset of rash. Exclude unimmunized students on same campus from date of diagnosis of first case until 14 days after rash onset of last known case or until measles immunization received or laboratory proof of immunity is presented or until history of previous measles infection is verified as per records or the Nebraska Department of Health |
| Mumps | 2-3 weeks | 20-40% of those infected do not appear ill or have | About 7 days before | Exclude until swelling has subsided. No exclusion of contacts. Inform parents of unimmunized students on campus of possible exposure and encourage immunization. |
| Pediculosis | Eggs of lice, | Itching; infestation of hair and/or clothing with insects and nits (lice eggs). | While lice remain alive and until eggs in hair and clothing have been destroyed. Direct and indirect contact with infested person and/or clothing required. | Exclude until after appropriate treatment is started. No exclusion of contacts; however they should be notified of exposure. |
| Pertussis | 7 days--usually | Irritating cough—symptoms of common cold usually | About 7 days after | Exclude until physician approves return as per written documentation. Exclude inadequately immunized close contacts as deemed appropriate by school officials following investigation by the local and/or state Department of Health and Human Services. Chemoprophylaxis may be considered for family and close contacts. Report immediately by telephone all cases to local and/or state health departments. |
| Poliomyelitis | 3-35 days; 7-14 | Fever, sore throat, malaise, headache, stiffness of neck | Not accurately known. | Exclude until physician approves return. |
| Ringworm | 10-14 days | Scaly oval patches of | As long as infectious | Exclude until treatment started. No exclusion of contacts. Good sanitation practices and don't share toilet articles. |
| Rubella | 14-21 days | Low-grade fever, slight general malaise; scattered | About one week before rash until rash has disappeared. | Exclude for duration of illness and for no less than 4 days* after onset of rash. Exclude unimmunized students on same campus from date of diagnosis of first case until 23* days after rash onset of last known case or until rubella immunization received or laboratory proof of immunity is presented. Report immediately by telephone all cases to local and/or state health departments. |
| Scabies | Infection caused | Severe itching; lesions around loose fleshy tissue (e.g., finger webs, elbows, | Until mites and eggs | Exclude until the day after treatment is started. No exclusion of contacts. |
| Shingles / Herpes Zoster | Latent form after primary infection with chickenpox. | Grouped small blisters (vesicles) often accompanied by pain localized to area | Physical contact with vesicles until they become dry. | Exclude children with shingles / zoster if the vesicles cannot be covered until after the vesicles have dried. Individuals with shingles /zoster should be instructed to wash their hands if they touch the potentially infectious vesicles. |
| Streptococcal | 1 to 3 days | Sore throat, fever, headache. Rough rash 12-48 hours later. | Until 24-48 hours after | Exclude until afebrile and under treatment for 24 hours. No exclusion of contacts. Early medical care important and usually requires 10 days of antibiotic treatment. Screening for asymptomatic cases not recommended. |
| Tuberculosis | Highly variable-- | Weakness, cough, | Until sputum is free | Exclude. Physician treatment essential. May return with documented physician approval. No exclusion of contacts. Skin test contacts and chemoprophylaxis with INH if positive (in absence of disease). Exclusion of nonpulmonary tuberculosis unnecessary. |
* Day of onset of specific symptom is counted as "day zero;" the day after onset is "day 1;" second day after onset is "day 2;" and etc.
NOTE: Careful handwashing is the most important thing that can be done to prevent the spread of most infectious diseases.
(To be filled out by the parent, guardian, or medical provider of the child/student. Print out and return to school nurse.)
This document is being submitted on behalf of:
_____________________________________________________________
(Name of child/student) (Birth date of child/student)
I ______________________________________ verify that the above listed
(Parent/guardian/medical provider)
child/student had the varicella disease in __________ (year).
________________________________________
(Signature of parent/guardian/medical provider)
Child’s Last Name________________________
First Name______________________
Age____ Birth Date_______ School____________________ Grade___
A. I have elected to not immunize this student against the following disease(s): (check box*)
Diphtheria...........................................................................................
Tetanus........................................................... ...................................
Pertussis.............................................................................................
Polio.................................................................... ...............................
Measles(Rubeola)..............................................................................
Mumps................................................................................................
Rubella (German Measles)................................................................
Hepatitis B................................ ..........................................................
In my opinion, this immunization would be injurious to the health and well-being of
The student........................................................................
A member of the student’s household or family..........................
B. I have elected to use the two-dose Hepatitis B vaccine series licensed by FDA for use in 11-15 year old adolescents. It could potentially be injurious to the student’s health to give a third dose that is not medically required to complete the series.
Comments __________________________________________________________
___________________________________________________________________
Signature of Physician___________________________________ Date___________
* Each disease for which a vaccine has not been administered must be checked. Parent / guardian must submit dates of immunization for all other diseases.