216-RICR-30-05-3. Immunization and Communicable Disease Testing in Preschool, School, Colleges or Universities (version Amendment, 05/14/2009 to 08/12/2014)

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) October 2002 June 1996 (E) June 2005 June 1996 November 1998 July 2001 January 2007 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) April 2009 January 2002 (re-filing in accordance with the provisions of section 42-35-4.1 of the Rhode Island General Laws, as amended) 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 for 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; and (2) duplication or overlap with other state regulations. No alternative approach, overlap or duplication 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. i TABLE OF CONTENTS Page Section 1.0 1 Definitions Section 2.0 1 General Requirements Section 3.0 2 Minimum Standards for Immunization & Communicable Disease Testing for Students Entering Preschools and Schools (K-12) Section 4.0 7 Severability References 8 ii Section 1.0 Definitions Whenever used in these rules and regulations, the following terms shall be construed as follows: 1.1 "Advisory Committee on Immunization Practices (ACIP) recommendations", as used herein, means official federal recommendations for the use of vaccines in the United States and as published by the Centers for Disease Control and Prevention. 1.2 “Director” means the Director of the Rhode Island Department of Health. 1.3 “Department” means the Rhode Island Department of Health. 1.4 “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. 1.5 “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. 1.6 “School” means all public or non-public schools for students in grades Kindergarten through 12 in Rhode Island. 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. The term “student” shall also include any person from another country attending or visiting classes or educational programs as part of a formal academic visitation or exchange program. 1.8 “Waiting period” means the time interval between scheduled doses of vaccine. The length of waiting periods are defined by the 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. 2.2 It shall be the responsibility of the administrative head of any preschool or school to secure compliance with these rules and regulations. 2.3 In accordance with ACIP recommendations, for all vaccines discussed herein, vaccine doses administered less than or equal to four (4) days before the minimum interval or age shall be counted as valid. Doses administered five (5) or more days earlier than the minimum interval or age shall not be counted as valid doses and shall be repeated as age-appropriate. The repeat dose should be spaced after the invalid dose by the recommended minimum 1 interval as provided in ACIP recommendations. (For more information, please see reference 1 herein). 2.4 Persons charged with reporting communicable diseases (e.g., physicians, physician assistants, registered nurse practitioners, midwives, laboratories, certified school nurse teachers and other entities or persons) shall comply with the most current version of the Rules and Regulations Pertaining to the Reporting of Communicable, Environmental and Occupational Diseases of reference 4 herein and the most current version of the Guidelines for Prevention and Control of Communicable Diseases issued by the Department. 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. 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, varicella (chickenpox), and pneumococcal disease. 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). 2 (i) For any student who is seven (7) to nine (9) years of age and requires additional vaccine doses to satisfy this requirement, Td (Tetanus-diphtheria toxoid) is to be used. (ii) If a child completing the series is greater than seven (7) years old and had a dose of Tetanus-Diphtheria containing vaccine administered prior to twelve (12) months of age, then four (4 ) doses shall be needed with minimum spacing between doses of four (4) weeks, four (4 ) weeks, and six (6) months. (iii) If the child completing the series is greater than seven (7 ) years old and did not have a dose of Tetanus-Diphtheria prior to twelve (12) months of age, then three (3) doses of vaccine shall be needed with minimum spacing between doses of four (4) weeks and six (6) months. If the primary series is completed on or after the tenth (10th) birthday, Tdap- should be substituted for one (1) dose in the series given after the age of ten (10), preferably the first dose after age ten (10). (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 on August 1, 2009, a single dose of Tdap vaccine shall be required for students attending seventh (7th) grade (or in the case of an ungraded classroom, for students twelve (12) years of age or older) if it has been more than five (5) years since the last dose of DTaP, DT, or Td. If it has been less than five (5) years since a student received his/her last dose of DTaP, DT, or Td, Tdap shall not be required, but may be administered according to the judgment of a physician, nurse practitioner, or physician assistant. 3.3.2 Poliomyelitis Vaccine (a) Upon initial entry to a school, a student is required to have received a total of four (4) doses of any combination of either oral poliovirus vaccine (OPV) or inactivated poliovirus vaccine (IPV), with at least four (4) weeks between doses. If the third (3rd) dose was given after the fourth (4th) birthday, a fourth (4th) dose is not necessary (total of three (3) doses), as long as all three (3) doses were either all OPV or all IPV; or a series administered in accordance with ACIP recommendations. (b) For students 18 years of age and older, poliovirus vaccine is not required. 3.3.3 Measles, Mumps, and Rubella Vaccines (a) Beginning on August 1, 2009, two (2) doses of live measles, mumps and rubella vaccine given at least four (4) weeks apart beginning at or after twelve (12) 3 months of age shall be required for students entering kindergarten (K) and grade seven (7) in accordance with ACIP recommendations. (b) Beginning on August 1, 2015, this requirement shall apply to all students attending grades K through 12 and all students in ungraded classrooms. The following dates are in effect for the grades, as specified below: August 1, 2009 K,7 August 1, 2010 K,1,7,8 August 1, 2011 K,1,2,7,8,9 August 1, 2012 K,1,2,3,7,8,9,10 August 1, 2013 K,1,2,3,4,7,8,9,10,11 August 1, 2014 K,1,2,3,4,5,7,8,9,10,11,12 August 1, 2015 K,1,2,3,4,5,6,7,8,9,10, 11, 12 3.3.4 Hepatitis B Vaccine Three (3) doses of hepatitis B vaccine for students attending kindergarten (K) through grade twelve (12) and all students in ungraded classrooms shall be required. 3.3.5 Varicella (Chickenpox) Vaccine Beginning on August 1, 2009, two (2) doses of varicella vaccine given at least four (4) weeks apart beginning at or after twelve (12) months shall be required for students entering kindergarten (K) and grade seven (7) (or in the case of an ungraded classrooms, students twelve {12} years of age or older). The following dates are in effect for the grades, as specified below: August 1, 2009 K,7 August 1, 2010 K,1,7,8 August 1, 2011 K,1,2,7,8,9 August 1, 2012 K,1,2,3,7,8,9,10 August 1, 2013 K,1,2,3,4,7,8,9,10,11 August 1, 2014 K,1,2,3,4,5,7,8,9,10,11,12 August 1, 2015 K,1,2,3,4,5,6,7,8,9,10, 11, 12 3.3.6 Meningococcal Vaccine (a) Effective August 1, 2009, all students upon initial entry to seventh (7th) grade, shall be required to receive one (1) dose of meningococcal (meningitis) vaccine, in accordance with ACIP recommendations. (b) Beginning August 1, 2014, this requirement shall apply to all students attending grades seven (7) through twelve (12) and all students in ungraded classrooms. The following dates are in effect for the grades, as specified below: August 1, 2009 7 August 1, 2010 7,8 August 1, 2011 7,8,9 August 1, 2012 7,8,9,10 August 1, 2013 7,8,9,10,11 August 1, 2014 7,8,9,10,11,12 4 3.4 Immunization Records 3.4.1 (a) Acceptable evidence of completion of immunizations shall include the day, month, year and type/name of each dose of vaccine administered. Such evidence shall consist of a record signed by a physician, registered nurse practitioner, physician’s assistant, 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. (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 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) presentation of laboratory evidence of immunity is made in the case of measles, mumps, rubella, hepatitis B and varicella (chickenpox); or, (e) For chickenpox (varicella), a physician, a physician assistant, a certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice signs a statement that the student has a history of chickenpox disease (varicella). (f) 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 5 (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. (c) If an outbreak of vaccine -preventable disease should occur, an exempt student shall be excluded from school by the administrative head of school for a period of time as determined by the Health Department based on a case-by-case analysis of public health risk. (d) The preschool or school shall have a written protocol in place for the exclusion of unvaccinated students in the event of an outbreak. An accurate and current listing of unvaccinated students shall be maintained by the preschool or school for this purpose. 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. (i) The administrative head of the preschool or school or his/her designee shall sign a Temporary Immunization Exemption Certificate, provided by the school, 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. (b) At initial preschool or school entry a student who is under the care of the state Department of Children, Youth and Families (DCYF) shall be enrolled in school upon presentation of a completed intra-state education identification card in 6 accordance with the requirements of section 42-72.4-1 of the Rhode Island General Laws, as amended, or as stipulated in section 3.4.1(f) herein. 3.5.3 Exemptions (a) A student may only be exempt from the immunization requirements described herein for either of the two (2) reasons stated below: (i) a physician, a physician assistant, a certified registered nurse practitioner, or other licensed practitioner acting within his/her scope of practice signs the Rhode Island Department of Health’s “Medical Immunization Exemption Certificate” provided by the school attesting that the student is exempt from a specific vaccine because of medical reasons, in accordance with ACIP recommendations, AAP guidelines, or package insert instructions; or (ii) a parent or guardian completes and signs the Department’s “Religious Immunization Exemption Certificate” provided by the school, attesting that immunization conflicts with the tenets of their religious beliefs. Section 4.0 Severability 4.1 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. Friday, 10 April 2009 K12_Immunzation_FinalRegs_April2009.doc 7 REFERENCES 1. CDC. General Recommendations on Immunizations: Recommendations of the Advisory Committee on Immunization Practices (ACIP) - MMWR, December 1, 2006 / 55(RR15);1- 48. Available online at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5515a1.htm 2. CDC. Recommended Immunization Schedules for Persons Aged 0-18 Years -- United States, 2008. MMWR, January 11, 2008 / Vol. 57 / No. 1. Available online at: http://www.cdc.gov/mmwr/pdf/wk/mm5701-Immunization.pdf. 3. "Department of Health", Chapter 23-1 of the Rhode Island General Laws, as amended. Available online: http://www.rilin.state.ri.us/Statutes/TITLE23/23-1/INDEX.HTM. 4. Rules and Regulations Pertaining to the Reporting of Communicable, Environmental and Occupational Diseases (R23-10-DIS), Rhode Island Department of Health, August 2008 and subsequent amendments thereto. Available online: http://www2.sec.state.ri.us/dar/regdocs/released/pdf/DOH/5335.pdf 5. Guidelines for Communicable Disease Prevention and Control, Rhode Island Department of Health, available online: http://www.health.ri.gov/disease/communicable/providerguide.pdf. 8