Report No. 2008-69
October 2008
Complete Audit Report

Better Procedures Needed to Ensure School Children Meet Immunization Requirements
The Department of Health and Senior Services (DHSS) is responsible for ensuring Missouri school children are appropriately immunized against vaccine preventable diseases. Superintendents of public and private schools are required to prepare and submit to DHSS a school summary report stating the immunization status of every child enrolled in or attending school in the superintendent's jurisdiction and a student exception report stating the names of any noncompliant students. Additionally, it is unlawful for any student to attend school unless the student has been properly immunized and can provide satisfactory evidence of such immunization, or unless the student has received appropriate approval for a medical exemption, religious exemption, or immunization in progress. Our audit concluded DHSS needs to do more to ensure students are properly immunized and schools report immunization information to DHSS.

Some schools did not submit school summary reports or submitted inaccurate reports
At least 169 schools did not submit the 2006-07 school summary report to DHSS as of November 13, 2006. For the 2007-08 school year, 172 of the 1,234 (13.9 percent) schools had not submitted school summary reports as of January 15, 2008, three months after the report due date. In addition, of 118 school summary reports tested for kindergartners during the 2007-08 school year, 16 (13.6 percent) were inaccurate. DHSS officials said there are no written policies for (1) when and how often a school is to be contacted to obtain delinquent school summary reports, and (2) the documentation required to support the follow-up performed with the school and the record retention period for such documentation.

DHSS did not ensure schools submitted accurate student exception reports
Reviews to ensure complete and accurate student exception reports are obtained from the schools were not initiated timely in the 2007-08 school year and were not completed in the 2006-07 school year. At the time of our review on February 19, 2008, 106 of 118 schools tested submitted 2007-08 school summary reports indicating they had kindergartners who were not in compliance with immunization requirements. As of May 6, 2008, 100 of the 106 schools had submitted a student exception report; however, 24 of the schools had submitted exception reports that were not complete and/or accurate. A DHSS official said there is no formal tracking performed to identify the schools that did not submit the required student exception report(s) to DHSS nor any documented policies for reviews.

Better regulations needed to protect non-immunized students during an outbreak
State regulations do not require schools to maintain a list of exempt students. Additionally, state regulations do not require exempt students to be excluded from school during outbreaks of vaccine preventable diseases. Changes are needed to ensure appropriate steps are taken in the event of an outbreak or epidemic.

DHSS not requiring compliance with federal recommendations
State law requires immunizations and their manner and frequency to comply with recognized standards of the medical practice. However, state regulations do not require the meningococcal vaccine or the human papillomavirus (HPV) vaccine and DHSS' immunization notifications sent to schools do not include requirements for school children to be vaccinated with the second dose of varicella, as federally recommended. In addition, DHSS' recommended administration of the tetanus, diphtheria, and pertussis (Tdap) booster for adolescents did not comply with federal recommendations. State regulations also do not require parents or guardians to be notified of any deviations from federal recommendations. The U.S. Department of Health and Human Services, Centers for Disease Control and Prevention guidance allows grantees 2 years to adjust assessment practices to reflect changes in Federal Advisory Committee on Immunization Practices (ACIP) recommendations. A DHSS official said the ACIP recommended the meningococcal and Tdap booster in 2005, and the HPV and second dose of varicella in 2006.

DHSS needs to make improvements in other areas
Further improvements are needed to (1) better validate the state's immunization rate reported to the federal government, (2) increase the functionality and reliability of the school children immunization database, (3) ensure compliance with legal provisions concerning appointments to the Advisory Committee on Childhood Immunization, (4) establish a standard immunization record requiring a physician or health care administrator's statement verifying the vaccine was administered, (5) establish regulations for the retention of immunization records, (6) improve the effectiveness of DHSS' immunization registry, (7) perform analyses to identify populations at risk for vaccine preventable diseases, and (8) report immunization information to more stakeholders.

Complete Audit Report
Missouri State Auditor's Office
moaudit@auditor.mo.gov