1. Tricia Washburn Rhode Island Department of Health Chief, Office of Immunization Rhode Island School Immunization Regulations

2. Presentation Overview Outline changes and rationale to the new “ Rules and Regulations Pertaining to Immunization and Communicable Disease Testing in Preschool, School, Colleges or Universities” Share school immunization assessment results from the 2013-2014 school year Update on HPV vaccination rates and state-wide activities.

3. Pre-school and Child Care Requirements Current Requirements New Requirements Effective August 1, 2015 Children: “Age appropriate immunization for all CDC recommended vaccines” includes DTaP, Hep B, Polio, PCV, HIB, MMR, Varicella Child care workers: no vaccines currently required in regulations Add vaccines for children:  Rotavirus  Hepatitis A  Annual Influenza (by Dec. 31) Add for child care workers: 1Tdap 2 MMR 2 Varicella Annual influenza (by Dec. 31)

4. Child Care Workers Regulations Rationale Historically DCYF regulations for licensed pre-school’s and daycare settings refer to HEALTH’s immunization regulations. DCYF was updating their regulations and HEALTH updated the immunization regulations to meet today’s national standards. Children 6 – 59 months are one of our most vulnerable populations as they are not fully vaccinated and more susceptible to negative outcomes from vaccine preventable disease.

5. Who does this apply to? “Child care worker” - Anyone who is temporarily or permanently employed by a preschool, daycare center, or home-based center that is licensed by the Rhode Island Department of Children, Youth, and Families (DCYF) and who has contact with children in that facility. People need to be vaccinated even if they have indirect contact with children.

6. Evidence of Immunity Evidence of Immunity for MMR: Born before 1957 (*presumptive immunity) Evidence of laboratory immunity (titer) Official record indicating vaccination date with mo/day/year

7. Evidence of Immunity Evidence of Immunity Chickenpox: Born before 1980 (*presumptive immunity) Evidence of laboratory immunity (titer) Official record indicating vaccination date with mo/day/year History of disease (including shingles) with signed statement from physician

8. Exclusion *In the event of an outbreak in a facility, which will be determined in consultation with HEALTH, individuals who have not shown proof of immunity, including those born before 1957 and 1980, may be required to show proof of immunity or be vaccinated before returning to work.

9. Kindergarten Requirements Current Requirements New Requirements Effective August 1, 2015  3 Hepatitis B  4-5 DTaP  3-4 Polio  2 MMR  2 Varicella Add: Polio change: All kids will need documentation of a dose of polio given after 4 years of age (even if 4 doses were given before 2 years)

10. Grade 7 Requirements Current Requirements New Requirements Effective August 1, 2015 1 Tdap 1 MCV Add: 3 HPV (males & females) Human Papillomavirus (HPV) Vaccine (a) Beginning August 1, 2015, all students upon entry to seventh (7 th ) grade, shall be required to have at least one (1) dose of the HPV vaccine series. (b) Beginning August 1, 2016, all students entering eighth (8 th ) grade shall be required to have at least two (2) doses of the HPV vaccine series. (c) Beginning August 1, 2017, all students entering ninth (9 th ) grade shall be required to have completed the HPV vaccine series (3 doses).

11. 7 th Grade Regulations Rational HPV vaccination is cancer prevention. HPV vaccine is no different than any other vaccine. HEALTH’s practice is to include all ACIP recommended vaccines into the school requirements. Goal is to protect the public’s health.

12. Grade 12 Requirements Current Requirements New Requirements Effective August 1, 2015 Evidence of all previously required vaccines Add: Booster dose of meningococcal vaccine (MCV) for entry into 12 th grade (CDC recommends booster at age 16 ) Note: this is required for students in 12 th grade because all students entering 12 th grade are at least 16 years of age.

13. College Requirements Current Requirements New Requirements Effective August 1, 2015 3 Hepatitis B 1 Td 2 measles/1mumps/1rubella 2 Varicella Meningococcal vaccine recommended only but colleges are required to provide educational information about meningococcal disease and availability of vaccine Add: 1 Tdap 2 MMR Meningococcal vaccine: (a) One (1) dose of meningococcal conjugate (MCV4) vaccine is required for previously unvaccinated newly enrolled full-time undergraduate and graduate students (under twenty-two (22) years of age) in a degree program at a college or university who will live in a dormitory or comparable congregate living arrangement approved by the institution. (b) Evidence of a second (booster dose) of MCV4 vaccine is required for incoming students (under twenty-two (22) years of age) if the first dose was given before sixteen (16) years of age.

14. Reporting Requirements The administrative head (or designee) of each preschool, school, college and university shall be responsible for reporting the immunization status of students and the number of students with a medical and/or religious exemption to the Department. Reporting on 12 th grade immunization coverage will likely begin school year 2015-2016. Reporting is critical for outbreak response and surveillance to assess and improve program policies.

15. Kindergarten Immunization Assessments 2013-2014 School Year 1

16. # of Schools with a Kindergarten # of Students enrolled in Kindergartens RIReportedRIReported Public167167 (100%)10,19410,194 (100%) Private6966 (96%)1,2841,227 (96%) Total236233 (99%)11,47811,421 (99.5%) 2013-2014 Kindergarten Immunization Assessments Number and Percentage of Kindergartens Reported 3

17. Kindergarten Immunization Rates* 2013-14 School Year, All Schools (Public & Private) * Coverage Rates as of 09/01/2013 Healthy People 2020 Target = 95% 4

18. Kindergarten Immunization Rates* 2012-13 vs. 2013-14 School Year, All Schools * Coverage Rates as of September 1 5

19. Kindergarten Immunization Rates* 2013-14 School Year, Public vs. Private * Coverage Rates as of 09/01/2013 6

20. Kindergarten Immunization Rates* for Public Schools 2012-13 vs. 2013-14 School Year * Coverage Rates as of September 1 7

21. Kindergarten Immunization Rates* for Private Schools 2012-13 vs. 2013-14 School Year * Coverage Rates as of September 1 8

22. Kindergarten Vaccine Exemptions 2013-14 School Year Number of Kindergarten Students Who Have an Exemption Public (n=10,194) Private (n=1,227) Total (n=11,421) Medical29433 Religious651580 Total9419113 9

23. Kindergarten Vaccine Exemptions 2012-13 vs. 2013-14 School Year Percent of K Students Who Have an Exemption by School Year PublicPrivateTotal 2012-13 sch yr (%) 2013-14 sch yr (%) 2012-13 sch yr (%) 2013-14 sch yr (%) 2012-13 sch yr (%) 2013-14 sch yr (%) Medical 0.3 0.40.3 Religious 0.70.61.51.20.7 Total 1.00.91.81.51.11.0 10

24. Public (94) Private (19) Total (113) DTaP59968 Polio61970 MMR761793 Hep B45954 Varicella791392 Kindergarten Vaccine Exemptions 2013-14 School Year Number of Students with an Exemption by Vaccine Type 11

25. Public (94)Private (19) Total (113) Medical (29) Religious (65) Medical (4) Religious (15) DTaP22370968 Polio20410970 MMR235341393 Hep B5401854 Varicella235621192 Kindergarten Vaccine Exemptions 2013-14 School Year Number of K Students with an Exemption by Vaccine and Exemption Type 12

26. 7 th Grade Immunization Assessments 2013-2014 School Year 1

27. # of Schools with 7 th Grade# of 7 th Grade Students RI*ReportedRI*Reported Public6360 (95%)10,99810,736 (98%) Private8277 (94%)1,5571,443 (93%) Total145137 (94%)12,55512,179 (97%) 2013-2014 School Year 7 th Grade Immunization Assessments Number and Percentage of Schools with a 7 th Grade * Data from Department of Education 3

28. 7 th Grade Immunization Rates* 2013-14 School Year, All Schools (Public & Private) * Coverage Rates as of 09/01/2013 4

29. 7 th Grade Immunization Rates* 2012-13 vs. 2013-14 School Year, All Schools * Coverage Rates: as of 09/01/2012 for 2012-13 school year and as of 09/01/2013 for 2013-2014 school year 5

30. 7 th Grade Immunization Rates* 2013-14 School Year, Public vs. Private * Coverage Rates as of 09/01/2012 6

31. 7 th Grade Immunization Rates* for Public Schools 2012-13 vs. 2013-14 School Year * Coverage Rates as of 09/01/2012 7

32. 7 th Grade Immunization Rates* for Private Schools 2012-13 vs. 2013-14 School Year * Coverage Rates as of 09/01/2012 8

33. 7 th Grade Vaccine Exemptions 2013-14 School Year Number of 7 th Grade Students Who Have an Exemption Public (n=10,736) Private (n=1,443) Total (n=12,179) Medical25631 Religious32537 Total571168 9

34. 7 th Grade Vaccine Exemptions 2012-13 vs. 2013-14 School Year Percent of 7 th Grade Students Who Have an Exemption by School Year PublicPrivateTotal 2012-13 sch yr (%) 2013-14 sch yr (%) 2012-13 sch yr (%) 2013-14 sch yr (%) 2012-13 sch yr (%) 2013-14 sch yr (%) Medical 0.2 0.70.40.20.3 Religious 0.3 0.90.4 0.3 Total 0.5 1.60.80.6 10

35. Public (57) Private (11) Total (68) HepB13417 MMR16824 Tdap32234 Varicella27633 Meningococcal41647 7 th Grade Vaccine Exemptions 2013-14 School Year Number of Students with an Exemption by Vaccine type 11

36. Public (57)Private (11) Total (68) Medical (25) Religious (32) Medical (6) Religious (5) HepB2111317 MMR6104424 Tdap14181134 Varicella9182433 Meningococcal16252447 7 th Grade Vaccine Exemptions 2013-14 School Year Number of 7 th Grade Students with an Exemption by Vaccine and Exemption Type 12

37. Rhode Island HPV Vaccination Coverage Rates

38. HPV Vaccination Coverage among Adolescents Aged 13-17 years by Gender, RI vs. US, 2013 Data Source: National Immunization Survey (NIS-Teen), 2013 *Among 50 States and DC RI Rank* [1] [1] [1] [1] Percent

39. Trends in Adolescent Vaccination* Coverage among Teens 13-17 years of age Rhode Island, 2008-2013 Percent HP2020 Goal = 80% NA Data Source: National Immunization Survey (NIS-Teen), 2008-2013 * Routinely Recommended Vaccines at 11-12 years

40. State-wide Activities to Increase HPV Vaccination Coverage Rates

41. HPV Public Health Campaign July, 2015 English and Spanish Print, radio, television Target audiences: - Healthcare providers - Parents of children11- 12 yrs.

42. HPV Campaign Messaging - Cancer Prevention - Safety and efficacy of vaccine - Three doses needed for full protection - Important for boys and girls

43. Public health partnership with The Wellness Company and the middle schools HPV 2 nd and 3 rd dose logistically challenging for parents Over 5,000 doses of HPV have been provided through the high school program Increase likelihood of series completion Expand Vaccinate Before You Graduate Program

44. Reminder/Recall Initiative State-wide using KIDSNET Automated calls and reminder cards 1 st Cohort: 10 years, 11 months - messaging about annual well child visit and all 3 adolescent vaccines recommended at 11-12 years. 2 nd Cohort:13 and 14 years of age identified as not completed 3 dose series – message includes importance of vaccination and completion.

45. Peer-to Peer Visits Physician consultant meets with provider practices who have low HPV coverage rates identified through KIDSNET. Assesses challenges, barriers and provides resources. Provides data and best practices to assist in improving HPV immunization rates

46. Partnership to Reduce Cancer Collaborate to offer an HPV focused plenary session at the Cancer Summit. Dr. Ailis Clyne: Challenges and Successes with HPV Immunization Dr. Robison: Rhode Island HPV Disease Incidence and Prevalence Dr. Tarro: HPV Oropharyngeal Cancers and Airway HPV Disease The Summit will be held on June 10 th.

47. Tricia Washburn Chief, Office of Immunization 401.222.5922 Tricia.washburn@health.ri.gov@health.ri.gov www.health.ri.gov