Mandates and More Julie Morita, M.D. Deputy Chicago Department of Public Health
Why are vaccines required for school entry?
School Vaccine Requirements Small pox vaccine required in Massachusetts 1855
School Vaccine Requirements Small pox vaccine required in Massachusetts Supreme Court confirmed compulsory vaccine laws a right of states 1855 Early 1900s
School Vaccine Requirements Small pox vaccine required in Massachusetts Supreme Court confirmed compulsory vaccine laws a right of states Requirements used in response to measles outbreaks 1855 Early 1900s Early 1970s
Measles Outbreak Control Alaska Existing vaccine requirement enforced Excluded students decreased from 7,418 to 51 Outbreak halted Los Angeles New requirement issued 50,000 of 1.4 million excluded from school Within days of exclusion, most students provided evidence of immunity Cases dropped precipitously
School Vaccine Requirements Small pox vaccine required in Massachusetts Requirements implemented before school entry Supreme Court confirmed compulsory vaccine laws a right of states Requirements used in response to measles outbreaks 1855 Early 1900s Early 1970s 1977
School Vaccine Requirements Small pox vaccine required in Massachusetts Requirements implemented before school entry Supreme Court confirmed compulsory vaccine laws a right of states All 50 states with school vaccine requirements Requirements used in response to measles outbreaks 1855 Early 1900s Early 1970s 1977 1990s
Illinois Requirements Daycare/Preschool Kindergarten 5 th grade 9 th grade DTaP HiB MMR Polio Pneumococcal Varicella DTaP MMR Polio MMR Polio Hepatitis B Td MMR Hepatitis B New adolescent vaccines not required Tdap*, MCV4, HPV Medical and religious exemptions allowed
Secondary Benefits of Vaccine Requirements Kindergarten requirements Contributed to high coverage levels Decreased racial and ethnic disparities in kindergartners Middle-school requirements Contributed to high coverage levels May decrease racial and ethnic disparities in adolescents
Factors to Consider before Requiring New Vaccines for School Entry Public acceptance of vaccines Accessibility of vaccines Healthcare provider acceptance of vaccines Healthcare system capacity to deliver vaccines
Vaccine Update, 2011
Immunization Schedules, 2011
Immunization Schedule Changes, 2011 Influenza vaccine Tetanus, diphtheria and acellular pertussis (Tdap) vaccine Meningococcal conjugate vaccine (MCV4) Human Papillomavirus vaccine (HPV)
Influenza
Seasonal Influenza Impact in US US population infected: 5% - 20% Higher infection rates in children Higher complications rates in Elderly Very young Pregnant women Persons with high risk conditions Influenza related deaths: ~3,000-48,500 Annual average hospitalizations: 220,000
Influenza among School-Aged Children Causes illness, hospitalization, and death Miss school, sports, work Highest attack rates during community outbreaks of influenza Serve as a major source of transmission of influenza within communities
Influenza Vaccine, 2010-2011 Universal influenza immunization recommended for all people > 6 months unless medically contraindicated
Mandatory Flu Vaccine for Healthcare Personnel Nationally, 55.5% of HCP received an influenza vaccines by November, 2010 Many organizations recommend that all health care personnel should be required to receive flu vaccine American Academy of Pediatrics American College of Physicians Infectious Disease Society of America Society for Healthcare Epidemiology of America
Adolescent Vaccines
Adolescent (13-17 yrs) Vaccination Coverage, 2009 100 80 60 40 20 76 71 72 54 58 54 44 36 34 26 16 25 0 Td or Tdap 1 MCV 4 1 HPV 1 HPV 3 Vaccines US Chicago Rest of IL
Tetanus, Diphtheria and Pertussis (Tdap)
Pertussis, 2010 California: 8,383+ cases, 10 deaths Highest number of cases since 1947 Illinois: 813 cases 648 cases reported in 2009 72% of cases in people under the age of 18 Chicago: 97 cases 53 cases reported in 2009
Tdap Vaccines Boostrix (GSK) 10-64 years of age Adacel (sanofipasteur) 11-64 years of age
Tdap Recommendations for Adolescents Adolescents should receive Tdap at the 11 to 12 year-old preventive healthcare visit Persons 13 through 18 years of age who have not received Tdap should receive a dose followed by Td booster doses every 10 years MMWR 2011; 60 (No. 1):13-5
New Tdap Recommendations* Children 7 through 10 years of age who are not fully immunized (including those with unknown pertussis vaccination status) should receive a single dose of Tdap Not fully immunized < 4 doses of DTaP 4 doses of DTaP and last dose was prior to age 4 years Adults 65 and older who have close contact with children <12 months Protect vulnerable infants too young to be immunized *off-label recommendation. MMWR 2011; 60 (No. 1):13-5
New Minimum Interval Recommendations* As of October 2010, Tdap can be given regardless of interval since last Td NO need to wait 2-5 years to administer Tdap following a dose of Td Longer intervals reduce injection site reactions; however, benefits of protection against pertussis outweigh risk for adverse events *off-label recommendation. MMWR 2011; 60 (No. 1):13-5
Human Papillomavirus Vaccine (HPV)
HPV-Associated Disease Type Women Men 16/18 70% of cervical cancer 70% of anal/genital cancer Transmission 6/11 90% of genital warts 90% of Recurrent Respiratory Papillomatosis (RRP) lesions Transmission 70% of anal and penile cancer Transmission 90% of genital warts 90% of RRP lesions Transmission Cervarix (GSK): 16 and 18 only Gardasil (Merck): 6, 11, 16 and 18
Licensed HPV Vaccines Gardasil (HPV4, Merck) Females and males 9 through 26 years or age Types 6, 11, 16, 18 Cervarix (HPV2, GSK) Females 10 through 25 years of age Types 16, 18 3-dose series recommended at 11-12 years of age Schedule: 0, 1-2 months, 6 months after first dose Catch-up unvaccinated 13-26 yr olds
HPV Vaccine for Males FDA licensed Gardasil (not Cervarix ) for males 9-26 years Genital warts caused by types 6 and 11 Anal cancer and associated precancerous lesions caused by types 16 and 18 Permissive CDC/ACIP recommendation Same schedule as females VFC covers for males age 9 through 18 years Variable coverage among private insurers
True or False? HPV vaccine can be given to females who are already sexually active
True Females who have become sexually active will still benefit from immunization and should be vaccinated Since HPV vaccine is preventative (not therapeutic), HPV vaccine should be administered prior to onset of sexual activity at 11-12 years of age
Adolescent (13-17 yrs) Vaccination Coverage, 2009 100 80 60 40 20 76 71 72 54 58 54 44 36 34 26 16 25 0 Td or Tdap 1 MCV 4 1 HPV 1 HPV 3 Vaccines US Chicago Rest of IL
HPV Vaccine Discussions with Parents Adolescent immunization schedule recommended as strongly as childhood schedule Cancer preventing vaccine Efficacious, safe Investing in future
Meningococcal Conjugate Vaccine (MCV4)
Meningococcal Disease At least 13 serogroups Most invasive disease: A, B, C, Y-W-135 Strains vary based on geography and age Transmission: respiratory droplet spread or direct contact Abrupt onset, rapid course of disease Case fatality rate: 9%-12% (up to 40% with meningococcemia) 1%-19% of survivors suffer serious sequelae including deafness, neurologic deficit, or limb loss
Rate per 100,000 Rates of Meningococcal Disease (C and Y) by Age, US, 1999-2008 1.4 1.2 1 0.8 0.6 0.4 0.2 Serogroup C Age for routine vaccination Serogroup Y 0 1 3 5 7 9 11 13 15 17 19 21 23 25 Age (year) Active Bacterial Core surveillance (ABCs), 1998-2008
Meningococcal Conjugate Vaccines (MCV4) Menactra and Menveo Approved for persons 2-55 years Prevent A, C, Y, W-135 infections Routine vaccination 11-12 years Booster dose: 16 years (new) Catch-up vaccination 13-15 years, if not vaccinated previously with MCV4 Booster dose: 16-18 years old (new) Minimum interval between doses: 8 weeks
MCV4 Booster Rationale Serologic data available that show significant decline in antibody 3-5 years after vaccination although few breakthrough cases have been reported MMWR 2009;58(No. 37):1042-3
New MCV4 Recommendations MCV4 recommended for all college students, not just those living in dorms Persons 21 years should have MCV4 not more than 5 years before entering college Booster not recommended for healthy persons if First dose was at 16-21 years Person is 22 years or older even if first dose was at 11-15 years Booster should always be MCV4 (not MPSV4)
Adolescent (13-17 yrs) Vaccination Coverage, 2009 100 80 60 40 20 76 71 72 54 58 54 44 36 34 26 16 25 0 Td or Tdap 1 MCV 4 1 HPV 1 HPV 3 Vaccines US Chicago Rest of IL
Questions?