216-RICR-30-05-3. Immunization and Communicable Disease Testing in Preschool, School, Colleges or Universities (version Periodic Refile, 01/02/2002 to 10/21/2002)

RULES AND REGULATIONS PERTAINING TO IMMUNIZATION AND TESTING FOR COMMUNICABLE DISEASES (R23-1-IMM) STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS DEPARTMENT OF HEALTH January 1995 As Amended: February 1996 (E) June 1996 (E) June 1996 November 1998 July 2001 January 2002 (re-filing in accordance with the provisions of section 42-35- 4.1 of the Rhode Island General Laws, as amended) i INTRODUCTION These amended rules and regulations are promulgated pursuant to the authority set forth in sections 16-38-2 and 23-1-18 of the General Laws of Rhode Island, as amended, and are established for the purpose of adopting standards pertaining to requirements for immunizations and testing of communicable diseases, including, but not limited to tuberculosis, for employees, children and students at any preschool or school in grades Kindergarten-12 in Rhode Island. Pursuant to the provisions of section 42-35-3c of the General Laws of Rhode Island, as amended, consideration was given to: (1) alternative approaches to the regulations; (2) duplication or overlap with other state regulations: and (3) significant economic impact placed on small business as defined in Chapter 42- 35 of the General Laws as a result of the amended regulations. No alternative approach, overlap or duplication nor any significant economic impact was identified, consequently the regulations are adopted in the best interest of the health, safety and welfare of the public. These rules and regulations (R23-1-IMM) shall supersede all previous Rules and Regulations Pertaining to Immunization and Testing for Communicable Diseases promulgated by the Department of Health and filed with the Secretary of State. ii TABLE OF CONTENTS Page SECTION 1.0 1 Definitions SECTION 2.0 1 General Requirements SECTION 3.0 1 Minimum Standards for Immunization & Communicable Disease Testing for Students Entering Preschools and Schools (K-12) SECTION 4.0 6 Minimum Standards for Immunization & Communicable Disease Testing for School Personnel SECTION 5.0 7 Severability 1 Section 1.0 Definitions 1.1 “Director” means the Director of the Rhode Island Department of Health. 1.2 “Department” means the Rhode Island Department of Health. 1.3 “Preschool”, as used herein, means all public and non-public child day-care centers, family day-care homes, nursery schools, or any licensed or certified program providing regular educational services to preschool-aged children in Rhode Island. 1.4 “Physician”, as used herein, means an individual licensed under the provisions of Chapter 5-37 of the General Laws of Rhode Island, as amended, or an individual licensed to practice allopathic or osteopathic medicine under the laws of another state or territory of the United States, provided those laws are deemed to be substantially equivalent to Chapter 5-37 of the Rhode Island General Laws, as amended. 1.5 “School” means all public or non-public schools for students in grades Kindergarten through 12 in Rhode Island. 1.6 “School personnel” means all persons employed directly by the school or under contract to the school. 1.7 "Student", as used herein, means any individual who is or has been enrolled, full time or part time, at a preschool or school. 1.8 “Waiting period” means the time interval between scheduled doses of vaccine. The length of waiting periods are defined by the Advisory Committee on Immunization Practices (ACIP). Section 2.0 General Requirements 2.1 Preschools and schools shall adopt, at a minimum, the standards of immunization and communicable disease testing in section 3.0 of these regulations. The Department is authorized under section 23-1-18 (9) of the Rhode Island General Laws, as amended, to establish minimum standards for immunization and testing for communicable diseases, including, but not limited to, tuberculosis, of school personnel and students at any preschool or school. 2.2 It shall be the responsibility of the administrative head of any preschool or school to secure compliance with these rules and regulations. Section 3.0 Minimum Standards for Immunization and Communicable Disease Testing for Students Entering Preschools and Schools (K-12) 3.1 Each student, upon initial entry to any preschool or school in this state, shall furnish evidence to the administrative head of the preschool or school (pursuant to the requirements of section 3.4 of these rules and regulations) that the student has been immunized, as required in sections 3.2, 3.3, and 3.4 herein, unless the student is in an exempt category. 2 3.1.1 For the immunization requirements stipulated in sections 3.2 and 3.3.1--3.3.5 below, a student who is not in compliance with these requirements shall be excluded from attending preschool or school until the requirements are met, unless the student belongs in an exemption category or is in a waiting period between doses as described in section 3.5 herein. Preschool Entry Requirements 3.2 No student shall enter a preschool without an immunization record as defined in section 3.4 below documenting that the student has been or is age appropriately immunized in accordance with the current Recommended Childhood Immunization Schedule approved by the Advisory Committee on Immunization Practices (ACIP)/American Academy of Pediatrics(AAP)/ American Academy of Family Physicians (AAFP) against diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, Haemophilus influenzae type b, hepatitis B, and, for students born after December 31, 1996, varicella (chickenpox). School Entry Requirements 3.3 Each student, upon initial entry to any school, shall furnish evidence as required in section 3.4 herein of having received the vaccines described below: 3.3.1 Diphtheria, Tetanus, and Pertussis (a) Upon initial entry to a school, a student is required to have received a primary series of at least three (3) doses of a vaccine against diphtheria, tetanus and pertussis, with at least four (4) weeks between doses, and two (2) boosters, the first at least six (6) months after the third primary dose, and the second after age four (4) (total of five (5) doses). If the first booster is given after age four (4), a second booster is not required (total of four (4) doses). (i) For any student who is seven (7) years of age or older and requires additional vaccine doses to satisfy this requirement, adult Td (Tetanus-diphtheria toxoid) is to be used. (ii) If the primary series is begun on or after the seventh (7th) birthday, two (2) primary doses of adult Td at least four (4) weeks apart, with a third (3rd) dose of adult Td six (6) months after the second (2nd) primary dose are to be used. (iii) Pertussis vaccine is not required for students seven (7) years of age or older. (iv) Pediatric Diphtheria-Tetanus toxoid (DT), instead of a vaccine against diphtheria, tetanus and pertussis, shall only be used when the provider is following current acceptable guidelines for valid contraindications for pertussis vaccine, as recommended by the Advisory Committee on Immunization Practices (ACIP) or the American Academy of Pediatrics (AAP). (b) Beginning August 1, 1999, upon entering seventh grade (or in the case of an ungraded classroom, for students twelve years of age or older), a student is required to have received a booster of Td vaccine, if it has been five years or more since the last dose of a diphtheria-tetanus containing 3 vaccine. Provided, however, only for the academic school year commencing in the Fall of 2001, evidence of a Td booster shall not be required upon entering seventh grade, but shall be required by the end of the June 2002 academic school year. 3.3.2 Poliomyelitis Vaccine (a) Upon initial entry to a school, a student is required to have received a primary series of three (3) doses of a poliovirus vaccine, either oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine (IPV), with at least four (4) weeks between doses, and one (1) booster dose after age four (4) (total of four (4) doses); or a series administered in accordance with ACIP recommended guidelines and schedule. If the third (3rd) dose was given after the fourth (4th) birthday, a fourth (4th) dose is not necessary (total of three (3) doses). (b) A sequential polio series is acceptable that includes a primary series of two (2) doses of IPV followed by two (2) doses of OPV or any combination of the two poliovirus vaccines for a total of four (4) doses, or is administered in accordance with ACIP recommended guidelines and schedule. (c) For students 18 years of age and older, poliovirus vaccine is not required. 3.3.3 Measles, Mumps, and Rubella Vaccines (a) All students who initially entered a school on or before August 30, 1995 are required to have received one (1) dose of live measles, mumps, and rubella vaccines on or after their first birthday. (b) All students who initially entered a school on or after September 1, 1995 are required to have received two (2) doses of a measles-containing vaccine (preferably MMR vaccine), one (1) dose of a mumps vaccine, and one (1) dose of a rubella vaccine. The first dose of these three vaccines must be given on or after the first birthday. The second dose of a measles-containing vaccine (preferably MMR vaccine) must be given at least one (1) month after the first dose. (c) Beginning August 1, 2001, all students in school are required to have received two (2) doses of a measles-containing vaccine (preferably MMR vaccine), one (1) dose of a mumps vaccine, and one (1) dose of a rubella vaccine prior to school entry. The first dose of a measles-containing vaccine, one (1) dose of a mumps vaccine, and one (1) dose of a rubella vaccine, must be given on or after the first birthday. The second dose of a measles-containing vaccine must be given at least one (1) month after the first dose. 3.3.4 Hepatitis B Vaccine (a) Upon initial entry to the following grades, a student is required to have received three (3) doses of hepatitis B vaccine, in accordance with ACIP guidelines. The following dates will be effective for grades, as specified: August 1, 1999 K August 1, 2000 K,1,7 August 1, 2001 K,1,2,7,8 4 August 1, 2002 K,1,2,3,7,8,9 August 1, 2003 K,1,2,3,4,7,8,9,10 August 1, 2004 K,1,2,3,4,5,7,8,9,10,11 August 1, 2005 K,1,2,3,4,5,6,7,8,9,10,11,12 (b) Effective August 1, 2005, all students, upon initial entry to a school, are required to have received three (3) doses of hepatitis B vaccine, in accordance with ACIP guidelines. 3.3.5 Varicella (Chickenpox) Vaccine (a) Upon initial entry to the following grades, a student is required to have received one (1) dose of varicella (chickenpox) vaccine on or after his or her first birthday or, if the first dose is given on or after the student’s thirteenth (13th) birthday, two (2) doses of varicella (chickenpox) vaccine, in accordance with ACIP guidelines. The following dates will be effective for grades, as specified: August 1, 1999 K August 1, 2000 K,1,7 August 1, 2001 K,1,2,7,8 August 1, 2002 K,1,2,3,7,8,9 August 1, 2003 K,1,2,3,4,7,8,9,10 August 1, 2004 K,1,2,3,4,5,7,8,9,10,11 August 1, 2005 K,1,2,3,4,5,6,7,8,9,10,11,12 (b) Effective August 1, 2005, all students upon initial entry to a school, are required to have received one (1) dose of varicella (chickenpox) vaccine on or after his or her first birthday or, if the first dose is given on or after the student’s thirteenth (13th) birthday, two (2) doses of varicella (chickenpox) vaccine, in accordance with ACIP guidelines. 3.4 Immunization Records 3.4.1 Acceptable evidence of completion of immunizations shall include the day, month, year and type/name of each dose of vaccine administered. The record of such evidence shall be signed by a physician or his/her designee (the signature of the student's parents is not acceptable). This record may be submitted to the preschool or school by a health care provider, another preschool or school, a parent or a guardian. (a) For students who initially entered a Rhode Island school on or before December 31, 1989, existing immunization records shall be deemed acceptable, provided the record contains a valid exemption form or contains documentation that the student has completed the required immunizations. 3.4.2 Acceptable evidence of completion of immunization consists of: (a) a written statement signed by a physician or his/her designee; or 5 (b) an official immunization record card, preschool or school immunization record, Medical Passport, World Health Organization immunization record, or other official immunization records acceptable to the Division of Family Health, Immunization Program of the Department; or (c) an electronically stored and/or transmitted documentary record (facsimile transmission, computerized record, including, but not limited to, a record obtained from the KIDS NET statewide registry or other statewide registry, record on magnetic media or similar record) as may be utilized by a preschool or school; or (d) telephone confirmation by the preschool or school of the existence of immunization records as defined above, provided all of the following conditions are met: (i) an acceptable documentary record is on file with the preschool or school officials at a preschool or school which the student previously attended, or is on file with a health provider, public health agency, other health professional or preschool or school official responsible for maintenance of immunization records; and (ii) telephone confirmation is obtained by a preschool or school official at the preschool or school in which the student enrolls; and (iii) telephone confirmation is sought and obtained within one (1) working day of the student's initial entry; and (iv) written documentation is made in the student's preschool or school health record of the telephone confirmation call, including the date and time of the call, the name, address, and telephone number of the person who confirmed the immunization status; and (v) a written documentary record of immunization is received by the preschool or school in which the student has enrolled within ten (10) working days of initial entry; and (vi) the preschool or school shall implement the telephone confirmation as described above, if a student is seeking entry and does not present a copy of immunization records. 3.5 Provisions for Exclusions, Waiting Periods and Exemptions 3.5.1 Exclusions (a) Students who have not received the minimum number of required immunizations, who are not in a prescribed waiting period between doses, as specified in section 3.5.2 (a) herein and who are not exempt pursuant to section 3.5.3 herein, shall be excluded from the preschool or school by the administrative head of the preschool or school, pending the completion of the required dose(s) of vaccine(s). (b) Students upon initial entry to any preschool or school shall be excluded unless evidence is submitted that the student has received initial dose(s) of required vaccine(s) for preschool or school entry as set forth in these rules and regulations herein. 6 3.5.2 Waiting Periods (a) If at initial preschool or school entry a student is within a waiting period for the minimum number of doses for a given vaccine, the student shall be registered and/or admitted to preschool or school. It shall be the responsibility of the administrative head of the preschool or school or his/her designee to ensure the completion of at least the minimum number of immunizations, following the prescribed waiting period(s) and consistent with the provisions of these rules and regulations. 3.5.3 Exemptions (a) A student may be exempt from the immunization requirements described herein provided that: (i) a physician signs a medical exemption stating that the student is exempt from a specific vaccine because of medical reasons, in accordance with ACIP guidelines, AAP guidelines, or package insert instructions; or (ii) a parent or guardian completes and signs the Immunization Exemption Form, provided by the Division of Family Health, Immunization Program of the Department, on the grounds of religious beliefs; or (iii) the administrative head of the preschool or school or his/her designee signs a Temporary Exemption Form, provided by the Division of Family Health, Immunization Program of the Department, indicating that an appointment with a health care provider for the required immunization(s) has been made. This temporary exemption shall expire on the date of the immunization appointment; or (iv) presentation of laboratory evidence of immunity is made in the case of measles, mumps, rubella, hepatitis B and varicella (chickenpox); or, (v) a physician signs a statement that the student has a history of chickenpox disease (varicella). Section 4.0 Minimum Standards for Immunization and Communicable Disease Testing for School Personnel 4.1 All school personnel who are in direct and regular contact with students shall comply with the immunization and testing requirements in section 4.0 of these rules and regulations. 4.2 Measles, Mumps and Rubella 4.2.1 All school personnel shall be required to furnish evidence of having been immunized against measles, mumps and rubella with a live virus vaccine on or after twelve (12) months of age. Persons vaccinated prior to 1968 must be revaccinated, unless documentation indicated that a live virus vaccine was used. 7 4.2.2 School personnel may be exempt from the immunization requirements listed in section 4.2.1 above, provided that: (a) the person was born on or before December 31, 1956 and therefore is considered immune; or, (b) the person has evidence of immunity as confirmed by serologic testing; or (c) a physician signs a medical exemption stating that the employee is exempt from a specific vaccine for medical reasons, in accordance with ACIP guidelines or package insert; or, (d) the person completes and signs the Immunization Exemption Form, provided by the Division of Family Health, Immunization Program of the Department, on the grounds of religious beliefs; or, (e) in the case of measles, the person has documentation of a physician diagnosed case of measles. 4.3 Tuberculosis 4.3.1 Prior to initial employment, all school personnel covered by section 4.1 of these rules and regulations shall file with the administrative head of the school, or his or her designee, a report from a licensed physician that the employee is free from infectious tuberculous disease based on a physical examination including the results of a Mantoux (PPD) test recorded in millimeters, performed not more than six (6) months before the report is filed. 4.3.2 If the Mantoux test is positive or a previous Mantoux test is known to have been positive, the physician's certification that the tuberculosis is not communicable shall be based on documentation of a chest x-ray taken not more than six (6) months prior to the certification. Section 5.0 Severability 5.1 If any provisions of these regulations or the application thereof to any facility or circumstances shall be held invalid, such invalidity shall not affect the provisions or application of the regulations which can be given effect, and to this end the provisions of the regulations are declared to be severable. July 25, 2001 immuntestingK-12-finalregs-july01.doc