1. School-Based Varicella Surveillance Palm Beach County, Florida 42 nd National Immunization Conference March 17, 2008 Savita Kumar, MD, MSPH Medical Epidemiologist Palm Beach County Health Department 561-804-7865 Savita_kumar@doh.state.fl.us

2. Contributors Barbara Johnson, RN, BSN Ginger Stanley, BHS Alina Alonso, MD Jean M Malecki, MD, MPH Special Thanks to: School Health Program, Palm Beach County Health Department School Health, Health Care District of Palm Beach Palm Beach County School Board District

3. Objective Surveillance Evaluate the effectiveness of vaccine delivery and coverage Control of Communicable Disease Identify cases and control transmission

4. Varicella Surveillance November 2006 Varicella became reportable in Florida School-Based Reporting Private Physicians Others (hospitals, day care centers)

5. Day Care Entry Requirement for Varicella in Florida Day Care Effective July 1, 2001, children attending child care facilities and family day homes are required to have varicella vaccine *Varicella vaccine is NOT required if there is a history of varicella disease documented by the healthcare provider on Form 680 (Florida Certificate of Immunizations).

6. School Entry Requirement for Varicella in Florida School – –One dose of varicella vaccine requirement started for Pre-K through K in 2001/2002 school year – –One grade was added each year 2006-2007 - Pre-K, K- 5 th grade (one dose) 2007-2008 – Pre-K, K- 6 th grade (one dose) 2008-2009 – Kindergarten (2 doses) Pre-K, 1-7 th grade (one dose)

7. School-Based Reporting Since 1999-2000, public schools have been voluntarily reporting varicella cases A School health nurse is assigned to each public school in PBC ( K-12 th grade) Developed partnership with School District, School Health Program at local taxing district, and the Health Department

8. School-Based Reporting cont’d School nurse completes a varicella reporting form for each varicella case Sends this form via fax to Epidemiology Program at Health Dept. (Epi investigates VPD in PBC) A letter is send to parents when a case is diagnosed in a class

10. Severity of Varicella Disease   Very Mild<50 lesion   Mild50 – 249 lesions Patient’s hand can be placed between lesions without touching other lesions   Moderate 250 – 499 lesions Patient’s hand cannot be placed between lesions without touching others   Severe>500 lesions Difficult to see the skin

11. School-Based Reporting cont’d Created sample letter to be sent to parents which is signed by Health Department and School Principal Varicella Q & A pamphlet sent along with letter Parents to contact their medical provider / PBCHD for varicella vaccine for their children or for adults their medical provider

12. School-based Reporting cont’d Epi staff work with school health nurses to investigate outbreaks At the annual public health update meeting for school health nurses Training re: reportable diseases Feedback re: reportable varicella cases

13. Findings

14. Reported Varicella Cases For School Year 2006-07 and 2007-08 2006-072007-08 Total Cases Reported 198117 ER visit31 Hospitalization20 * Cases reported until Feb 29, 2008

15. Reported Varicella Cases For School Year 2006-07 and 2007-08 2006-072007-08 Total Cases Reported 198117 Varicella Exemption 5/183 (2.7%)4/94 (4.2%) Hx varicella Disease 23/198 (11.6%)14/116 (12.1%) Hx varicella vaccine 154/198 (77.8%)89/116 (76.7%) * Cases reported until Feb 29, 2008

16. Varicella Cases by Age for School Year 2006-07 & 2007-08 2006-072007-08 Children < 4 Years 3 (1.5%) All had vaccine, mild 3 (2.6%) 1had vaccine, moderate 4 – 18 Years (School age)194 (97.9%)112 (95.8%) >18 Years (Adults) 1 (.6%) None had vaccine 2 (1.6%) None had vaccine Total198117 * * Cases reported until Feb 29, 2008

17. Varicella Cases Diagnosed By for School Year 2006-07 & 2007-08 2006-072007-08 Physician135 (69.5%)88 (80.0%) Nurse22 (11.3%)9 (8.2%) Parent37 (19.2%)13 (11.8%) Total194110 * * Cases reported until Feb 29, 2008

18. Varicella Cases Reported BY for School Year 2006-07 & 2007-08 2006-072007-08 Physician6 (3.0%)7 (6.0%) School190 (96.0%)108 (92.3%) Others2 (1.0%)2 (1.7%) Total198117 * * Cases reported until Feb 29, 2008

19. Varicella Cases Classified by Severity of Varicella Disease 2006-072007-08 Very Mild96 (60%)54 (63.5%) Mild49 (30.6%)24 (28.3%) Moderate12 (7.5%)7 (8.2%) Severe3 (1.9%) All were 12-13 yrs old, 2 had no vaccine, one had it at age 18months 0 Total16085 * * Cases reported until Feb 29, 2008

20. Varicella Cases Reported by Grade, 2006-07 and 2007-08 2006-072007-08* Pre-K3 (1.5%)1 (.9%) KG21 (10.9%)7 (6.4%) ELEM112 (58.5%)70 (64.8%) MS47 (24.6%)24 (22.2%) HS8 (4.1%)6 (5.5%) 191108 * cases reported until 2/29/2008

21. Varicella Cases Reported by Month, 2006-07 and 2007-08

22. Summary

23. Summary cont’d Varicella disease is reportable in FL since Nov 2006 Majority of the cases are reported by schools even when they are diagnosed by physicians Majority of the cases have mild disease and had one dose of vaccine

24. Summary cont’d Developing partnerships early on goes a long way Share the data and findings with your partners. They feel that they are part of the team and will report the cases Meet with them annually to keep reminding them to report cases and to get their feedback

25. Thank You Questions??