American Camp Association Immunization Recommendations for International Staff

By Marla Coleman

While international staff members provide a valuable contribution and enhance the camp experience, they also can unwittingly introduce a foreign illness into the camp community. And because camp is a “closed” community, two or more cases of similar symptoms are actually considered an outbreak by the Centers for Disease Control (CDC).

As a result of learning this information “the hard way,” (i.e., by way of several such outbreaks last summer), the American Camp Association (ACA) is partnering with the CDC to offer recommendations for international staff members who may be arriving from countries with immunization policies not consistent with those in the U.S.

The guidelines are suggestions, not mandates, but have been formulated to help camp directors make informed choices to guard against the re-emergence of illnesses that virtually have been stamped out of American vocabulary because of the U.S.’s aggressive childhood immunization policy. While all the international agencies have been advocates for this information and have fully cooperated in the process, it is impossible for them to require immunizations that are not necessitated by the U.S. Immigration Office.

The CDC has identified a large outbreak of mumps that began in December 2005. The majority of cases are occurring among persons eighteen to twenty-five years of age — many of whom have been vaccinated. Additional cases of mumps are also under investigation in Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, and Wisconsin.

Last spring, there was a major outbreak (40,000 cases!) of mumps in the U.K. among college-age students (as this immunization is not required)! Several international staff members were incubating the illness as they made their way overseas and unknowingly introduced the mumps to their new camp community. While 100 percent of the camper population and American staff had been properly immunized, some of them did indeed become ill. The CDC confirmed that there is a standard 5 percent failure rate among all vaccines.

Lessons Learned

• Do not assume all international staff members have the same inoculations
• Make sure you have documentation for all members of the camp community, including “older staff” who may have difficulty obtaining records
• Communicate key messages openly and clearly if an outbreak does occur (see the sidebar on page 3) and tailor messages to different populations
  • Parents
  • Staff
  • Campers
  • Community
  • Media
• Partner with state and local health authorities
  • Recognize their expertise and participate with them as a full partner, remembering your obligation in loco parentis to advocate for your campers and staff without compromising the safety of the camp community
• Review your medical crisis management plan
• Consider implementing your own immunization requirements to safeguard your camp community (you
  can stipulate your own camp regulations regarding vaccines and offer prospective staff members the opportunity to
  be immunized)

Opportunities Gained

• Alliances with parents, staff, health officials, and the outside community
• Increased confidence of parents who appreciate your care-taking
• Heightened sense of bonding and compassion around a "shared story" (the real definition of "community"!) —
  "we're all in it together!"

ACA Immunization Recommendations

Due to the growing presence of international workers in summer camps throughout the United States, the following immunizations should be considered for all summer camp employees. These recommendations are based on provisions of the current recommendations of the Advisory Committee for Immunization Practices (ACIP)¹ and New York State Public Health Law 2167². They are intended for non-U.S. residents entering the U.S. for a limited period of time to work in a summer camp. For further details and special circumstances, consult ACIP publications or the National Immunization Program of the Centers for Disease Control and Prevention³.

Recommendations for administration of vaccines for summer camp counselors and seasonal camp workers are organized into the following three broad disease categories:

1. The following immunizations are strongly recommended:
   • Measles, mumps, and rubella diseases (MMR vaccine) because these vaccine preventable diseases are highly
     communicable. At a minimum this would require:
     • One dose of measles vaccine, one dose of mumps vaccine, and one dose of rubella vaccine (MMR), administered no more than four days before the first birthday; or
     • Diagnosis by a physician, physician assistant, or nurse practitioner as having had measles or mumps disease (not rubella); or
     • Demonstrated serological evidence of measles, mumps, or rubella IgG antibodies.
   • Tetanus Toxoid because the camp environment increases the risk of exposure to C. tetani bacteria.
   • One booster dose of tetanus containing vaccine within past ten years.
   • Tdap (adolescent and adult tetanus, diphtheria, and acellular pertussis) vaccine is the preferred immunization; however, Td (adult tetanus and diphtheria) may be used.
     
     It is important to remember that the MMR can be administered at any age from one year to adult. Camps should encourage adult staff who are not immunized or protected from having the disease to get the immunization.
      
2. The following immunizations may be indicated in certain circumstances (i.e., health workers, lifeguards, international travelers, and college students):
   • Hepatitis B
   • Hepatitis A
   • Meningococcal meningitis (MCV4 or MPSV4)
      
3. The following are additional immunizations recommended for all adults:
   • Varicella (chickenpox) — in absence of disease history
   • Poliovirus — if not previously vaccinated with either inactivated or live oral vaccine

Marla Coleman is the immediate past president of the American Camp Association. She is co-owner of Coleman Family Camps, which includes Camp Echo and Coleman Country Day Camp.

Key Messages for the Media

• Nothing is more important to an American Camp Association accredited camp than the health, safety, and well being of all campers.
• Camp XYZ demonstrated its commitment to the health and safety of its campers by employing excellent health policies and procedures and taking proactive steps when camp staff identified a health concern.
• Nearly 25,000 international counselors work in ACA-accredited camps each summer. This experience provides important lessons in understanding and cooperation in a world often full of strife.
• Unfortunately, a global health issue surfaced this summer over required immunizations. This is not a Camp XYZ problem, but a societal issue.
• 100 percent of campers at Camp XYZ had already been immunized before coming to camp, and the camp had documentation of immunization for each camper.
• Camps and other "closed" communities should be equally proactive in identifying symptoms; other cases have been identified in other states in the U.S.
• Our excellent health records and aggressive action — which included partnering with parents, counselors, doctors, and governmental agencies — allowed us to resolve the health issue quickly and completely.
• As a global society, we must work together to advocate for full immunization for internationals visiting our country.

Originally published in the 2006 Spring issue of The CampLine.