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More immunizations being required by schools

Each year from 1990-1994, about 14,500 people were hospitalized due to chickenpox or its complications.

[Follow the leader] [Required immunizations]

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September 1998

ATLANTA - The last trend in school-entry immunization requirements focused on hepatitis B, but the number of states requiring varicella vaccination is growing, according to Jane Seward, MBBS, MPH, chief of Varicella Activity at the National Immunization Program.

On April 1, 1997, Washington, D.C., became the first U.S. school district to require varicella immunization for school entry. Beginning with the 1997-1998 school year, varicella vaccination was required for children 12 months and older attending day care, those in pre-kindergarten through second grade and fifth grade through seventh grade students.

By the 2010-2011 school year, it is estimated that the district will require all students through college and up to 26 years to be immunized for chickenpox. The only licensed varicella vaccine (Varivax, Merck & Co.) became available to the private sector in May 1995, but did not fully reach the public sector until late 1996.

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State Requirements for Varicella Vaccination*
State	Date enacted	Child care entry requirement	Date effective	School entry requirement	Date effective	Grades	Comments
District of Columbia	4/1/97	X	4/1/97	X	4/1/97	Pre-K, K, 1st, 4th, 5th, 6th	Within three years, all children in child care and children from pre-K through 9th grade will be covered.
Massachusetts	5/19/98	X	8/1/98	X	9/1/98	K and 7th	Beginning in 2005, this requirement will extend to all grades K through 12.
Oklahoma	4/98	X	Spring 1999	X	9/98	K
Maryland	-	X	9/1/98	X	2000 for Pre-K; 2001 for K	Pre-K and K
Oregon	-	X	9/2000	X	9/2000	K and 7th
* as of July 31, 1998 Requirement applies to all children born after January 1, 1997							Source: CDC

Many other states are now following Washington, D.C., in requiring varicella vaccination; the current number is five. As of Aug. 1, children attending day care in Massachusetts are required to have the immunization, and a regulation has passed for school entry. This follows an outbreak in the state last year of invasive group B streptococci which occurred concurrently with chickenpox in two children in a Boston child care center.

Other states with varicella requirements in place include Oklahoma, Maryland and Oregon. Other states, however, are in the process of developing requirements for varicella immunization for school entry. Officials from Connecticut, New York, Florida and Michigan have reported to the CDC that they are considering the requirement.

"There may be others we don’t know about," Seward said. "The process takes six to 12 months, at least, to go through, although each state varies."

States cannot require the vaccination the year after the vaccine is approved because there would not be enough vaccine supply or staff to administer it, and the state may not be able to afford to cover the cost of the vaccine in the public sector.

Public use and acceptance must be optimal before a recommendation can be implemented.

Seward also mentioned herd immunity. If some children are vaccinated against the disease, it helps spread immunity to other children who cannot be vaccinated. Parents should be informed that it’s not only their child who benefits, but others may as well, she said. The vaccine is contraindicated for children with cancer or those taking steroids, for example, but those children can develop immunity through contact with immunized children.

Varicella vaccination is recommended for children 12-18 months of age as part of the harmonized childhood immunization schedule, approved by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices and the American Academy of Family Physicians.

The recommendation also states that susceptible adolescents and adults be vaccinated.

Every year 100 people die from chickenpox; one adult and one child per week Two-thirds of all people hospitalized are children, and 40 to 50 previously healthy children die each year from the disease or its complications, according to the Centers for Disease Control and Prevention (CDC).

Chickenpox during pregnancy can also lead to severe complications for newborns. A high mortality rate is associated with newborns whose mothers developed chickenpox either five days before or two days after delivery.

The Council of State and Territorial Epidemiologists recently recommended all states begin the process of requiring varicella immunization for school entry by 1999. The harmonized childhood immunization schedule, supported by the Advisory Committee on Immunization Practices, American Academy of Family Physicians and the American Academy of Pediatrics, recommends varicella vaccine for children at 12-18 months of age.

"I think varicella vaccination will become more important. Children will have a greater chance of not being exposed to chickenpox as the incidence of chickenpox goes down," she said. "It’s better to be vaccinated than be exposed to the risk of disease."

Most states have had general immunization requirements since the early to mid 1980s. In the 1960s, only smallpox and diphtheria-tetanus-pertussis immunizations were required; polio and measles-mumps-rubella followed.

"The most significant method to increase compliance with immunization recommendations was to make immunizations a requirement of school entry," Snyder said.

Based on 1996-97 state immunization requirements, most states require for school entry immunization with all six vaccines included in the harmonized childhood immunization schedule, although some also require immunizations for day care entry.

The 1997-98 entry requirement assessments are incomplete, but some states may have adopted hepatitis A and hepatitis B immunization requirements, said Bob Snyder, vaccine coordinator, Division of Immunization Services with the National Immunization Program. "But I don’t think it will be near the number of states that have adopted varicella."

Oklahoma will require as of Nov. 1 that all children entering kindergarten and seventh grade receive hepatitis A vaccine. (See article in the August issue of Infectious Diseases in Children.)

Required immunizations

While some states do not require all immunizations for school entry, Snyder said many children are immunized upon advice to the parents about the importance of vaccines. However, the school entry requirements remain an effective way to maintaining high immunization coverage rates, Snyder said.

Despite the high coverage levels, he said school districts have not dropped that condition of entry so it remains one of the reasons for such high coverage levels, in addition to similar day care and head start entry requirements.

"School-entry immunization requirements are still one of the main authoritative tools that we have to insist that immunization continue to be done," Snyder said. "You still need them to get into school."

Snyder said rotavirus (RotaShield, Wyeth-Lederle) and Lyme disease (LYMErix, SmithKline Beecham) — in the northeastern states only — may be the next vaccines required for school-entry. Influenza (FluMist, Aviron), however, will not likely become a school entry requirement because of the difficulty in tracking a yearly immunization.

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Copyright 2000, SLACK Incorporated. Revised 15 September 2000.