Risk Summit 2015:UC Immunization Plan

David Baron, MD—UCLA

Mary Knudtson, DNSc, NP, FAAN--UCSCMary Ferris, MD—UCSB

Adele Anfinson, MHA—UCSFTom Ferguson, MD, PhD—UCD

Gina Fleming, MD, MSPH—UCOP

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November – December,

2013

WHY VACCINATE: YOU DON’T WANT THIS TO HAPPEN AT YOUR CAMPUS!

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Significant Risk to Campus Community

• 17, 540 meningitis shots given at UCSB (2014)• 1200 doses of antibiotic prophylaxis• 611 extra visits to Student Health • Many extra Emergency Department visits• 273 calls to the 24/7 answering service

UC Immunization Plan: Overview

1.Overview of diseases targeted by the policy and their epidemiology

2.Rationale and History3.Barriers and Solutions4.Overview of 3 year plan and progress to

date5.Next steps

Overview of  diseases targeted by the policy and their epidemiology

1. Pertussis2. Measles3. Mumps4. Varicella5. Meningococcus6. Hepatitis B7. Tuberculosis

Pertussis

• Also called whooping cough• causes prolonged coughing

spells for weeks to months that can end in vomiting I

• can lead to pneumonia, seizures (jerking and staring spells), brain damage, and death

CALIFORNIA:• 11,168 reported cases with 2014

onset;)– 428 cases hospitalized; 102

(24%) have required intensive care• Most (60%) hospitalized

were <4 months of age– 3 deaths in infants <2 months

of age• 1,674 cases with onset in 2015

reported– Including 54 hospitalized and

one infant death

Pertussis Incidence in CA Over Time

Measles

• This virus causes a rash, cough, runny nose, eye irritation, and fever

• It can lead to ear infections, pneumonia, seizures, brain damage, and even death

• Can result in fetal deformity, brain damage and death when contracted during pregnancy by non-immune mother

Measles Cases in CA: 1994-2014

Mumps: Do you know this child?

• This virus causes fever, headache, swollen glands and painful swelling of the testicles or ovaries

• It can lead to deafness, meningitis (infection of the brain and spinal cord covering), sterility, and, rarely, death

2006: multi-state mumps outbreak involving more than 6,500 reported cases, mostly college-aged students mainly in the Midwest2007-2008: number of reported cases returned to usual levels (several hundred cases per year), and outbreaks involved fewer than 20 cases.2009- 2010: two large outbreaks occurred.

• One outbreak involved about 3,000 people and mostly affected high school-aged students in religious community in New York City

• The second outbreak involved about 500 people, mostly school-aged children, in the U.S. Territory of Guam.

2011-2013: there were several smaller mumps outbreaks reported on college campuses in California, Virginia, and Maryland. 2013: 438 people from 39 states in the U.S. were reported to have mumps2014: 1,151 mumps cases reported in US• Since November 2014, CDC has received reports of people with mumps, who

are affiliated with professional hockey teams. CDC is working with the states affected, as they conduct public health investigations

Mumps Outbreaks in the US

Varicella

• Also known as Chickenpox, this virus causes a rash, itching, fever, and fatigue

• While chickenpox is usually a mild illness, it also can lead to severe skin infections, scars, pneumonia, brain damage, or death

Meningococcal Disease

• A typically severe bacterial infection that can cause hearing loss, learning problems, brain damage, or loss of limbs.

• About 1 in 10 people with meningococcal disease will die from it.

• The disease is spread when people live in close contact or through other close contact such as partying or kissing.

• Teens and young adults have a higher risk for meningococcal disease

Invasive Meningococcal Disease (IMD) and college students

• Since 2009, 41 IMD cases in college students have been identified in CA - of the 36 with known serogroup:

• Most IMD cases are not associated with other cases, however even one case can trigger public anxiety

Men B vaccine recommendation

• ACIP working group reviewing national data and considering whether a recommendation should be made for adolescent vaccination – anticipated to be on agenda for June 25 meeting

• If no national recommendation for MenB, should California consider a recommendation?– Incidence of serogroup B disease in

adolescents/young adults higher in CA than nationally • ABCs estimate ~0.10/100,000 serogroup B• CA estimate ~0.30/100,000 serogroup B

Hepatitis B

• A serious liver disease that can cause short-term appetite loss, diarrhea, vomiting, fatigue, jaundice (yellow skin or eyes), and/or pain in muscles, joints, and stomach.

• It also can cause long-term (chronic) illness that leads to liver damage (cirrhosis), liver cancer, and death

• CA law requires vaccination of college students age 18 and younger; currently a requirement at UC

Tuberculosis

• A disease caused by a bacterium called Mycobacterium tuberculosis

• The bacteria usually attack the lungs, but can infect any part of the body, such as the kidney, spine, and brain.

• If not treated properly over several months, tuberculosis can be fatal.• 2013-2014: California 18-24 year olds*

– 61% foreign-born– Most common countries of origin among FB are Mexico, Philippines, Vietnam,

Guatemala, India, China.– Among foreign-born, 12.9% had student status at first entry to US.

(7.9% of all 18-24 yo).– 29% were reported as “not seeking employment” which includes

students, as well as homemakers, children, institutionalized persons, and those receiving permanent disability benefits.

*data from TB branch, CDPH May 29, 2015

UC Immunization Plan: Rationale and History

Tom Ferguson, MD, PhD-Medical Director, UCDDavid Baron, MD—Executive Director, Ashe Student Health Center, UCLA

UCLA Immunization Plan

• Spring 2013– UCLA submits plan to campus leadership proposing all

students submit vaccination history– Goal: to identify unvaccinated in case of outbreaks

• Fall 2013– UCLA shares plan with other campuses and suggests other

campuses also consider implementing• Winter 2014

– SHS Directors discuss UCLA proposal, and vote to expand UCLA’s proposal to include adoption of CDPH recommendations for immunization of college-age students

– Decide to start with educational phase and gradually phase in requirement

Outbreaks on Campuses

• Berkeley– Measles case(s)– Mumps

• Davis– Mumps in international student – Measles international student– 4 cases of Active Tuberculosis in 2014-15 – Meningitis Type B single case

• Most campuses– Active tuberculosis cases (including MDR TB)

• Santa Barbara– Meningitis (type B) outbreak November 2013– 4 cases in 2 weeks

UC Immunization Plan: Barriers and Solutions

Adele Anfinson—Director, Student Health and Counseling Services, UCSF

Mary Ferris, MD—Executive Director, Student Health Services, UCSB

What’s Different Now? COST

1.ACA Immunization Coverage: routine immunizations no cost-sharing

2.UC SHIP Immunization benefit: ACA compliant benefit

3.More compelling reason to vaccinate given increase in outbreaks (sometimes very public)

What’s different Now– data management?

1.Students and University more accustomed to doing business online

2.All UC Student Health centers have an electronic medical record system with a secure data submission portal for immunizations and TB screening data

Collecting and Validating data – Substantial

• Collection: At a minimum, must collect vaccine and titer dates with some level of validation.

• Communication: Manage a communication process with student who have many questions!– Staff to manage communication– Staff to answer incoming questions – Student Health,

Registrar, Programs?• Monitoring: Create and manage a process

to set registration holds

Implementation Challenges

• Students feeling a punitive relationship with SHCS if on hold

• Can’t find records – “lost or lazy”• Annual reassessment of process - takes focus• Pre-entry requirement or majority of cost on SHIP• Clear communication to students

– How to submit information– Students don’t understand requirements well, especially

when titer in mix• Follow up for chronic Hep B and latent TB – more

resources

Past Barriers to Immunization

•Cost of Vaccine, only covered in specific offices

•Inadequate record keeping

•International variation in immunization practices •Resource intense process to collect

and validate immunization history

Illegible & Incomplete Immunization Records

Immunization Record Validation

• Need to decide how to validate student-entered vaccination history– All vs random sample of records?– Campus-based decision or system-wide

• Impacts staffing and resources

Immunization Exemption Decisions

• Autism fears supplanted now with “free choice” argument; however Public Health needs override

• CA legislation pending that may remove “religious” and “personal belief” exemptions in K-12– UC to be consistent?

• Need a process for exemption waiver requests• Convening “Exemption Work Group” this summer

– To include representatives from SHS, students, faculty, International Studies, Registrars, Legal, Risk, VCSA

Different campus populations

• Who are affected by the policy?– Grad students, international students,

residential extension students, study abroad students?

– How to communicate policy and monitor compliance in special populations?

Overview of 3-Year Plan and Progress to Date

Mary Knudtson, DNSc, NP, FAAN—Executive Director, UCSC Student Health Services

Overview of three year planCalifornia Dept of Public Health IMMUNIZATION & SCREENING RECOMMENDATIONS FOR COLLEGE STUDENTS All students are strongly encouraged to obtain these vaccines prior to starting classes (currently voluntary except for health profession students, and Hepatitis B for students under the age of 19).

Recommended Vaccination Doses Recommended Vaccination Doses

Measles, Mumps and Rubella (MMR) 2 doses; first dose on or after 1st birthday

Varicella (chickenpox) 2 doses; first dose on or after 1st birthday

Tetanus, Diphtheria and Pertussis (Tdap) 1 dose in the last 10 years.

Meningococcal conjugate (preferred to polysaccharide vaccine)

One dose on or after age 16 for all undergraduates (and for graduate students new to residence hall settings)

Meningococcal serotype b Recommendations pending from the Advisory Committee on Immunization Practices.

Hepatitis B 3 doses

Screening for Tuberculosis All incoming students who are at higher risk for TB infection

Additional immunizations recommended—not part of the Immunization Plan

• Influenza vaccine (annual) • Hepatitis A vaccine • Human papillomavirus vaccine (women and men through age 26 years) • Pneumococcal vaccine (students certain medical conditions e.g., severe asthma, diabetes, chronic liver or kidney disease ) • Poliovirus vaccine (if series not completed as a child) • Vaccines for international travel, based on destination.

Fall 2015

• VACCINATIONS AND SCREENING ARE VOLUNTARY FOR FALL 2015, – WITH THE FOLLOWING EXCEPTIONS: – • Hepatitis B vaccine is mandatory for all

students under the age of 19 – • Health profession students have additional

requirements

Fall 2016

• Starting Fall 2016, all incoming students will be required to receive the vaccinations and tuberculosis screening per the CDPH recommendations in the chart above.

Fall 2017

• Registration holds will be placed on students who have not met the requirement

Progress to date

• Registrars, VCSA’s, Admissions at all campuses are aware of requirements

• All new incoming students are being notified

• EMR has immunization module for students to input data (or is in process of updating it)

Next steps

• Exemptions policy• Communication plan• Verification• President Napolitano's decision memo

support

THANK YOU!!!Questions?