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Current Trends Immunization Practices in Colleges -- United States

Outbreaks of vaccine-preventable diseases continue to occur in colleges. In 1985, 354 measles cases were reported on 26 college campuses. In 1986, the United States had a provisional total of 6,273 measles cases; 174 (2.8%) of these occurred on 21 campuses. Despite longstanding primary school immunization requirements, 5%-20% of college students still do not have documented immunity to measles and/or rubella (1.2).

In May 1983, the American College Health Association (ACHA) adopted a Preadmission Immunization Policy, recommending that, by September 1985, colleges and universities require all students to present documentation of immunity to measles, rubella, and other vaccine-preventable diseases as a prerequisite to matriculation or registration (3.4). Likewise, since 1980, the Immunization Practices Advisory Committee has recommended that college and university administrations strongly consider establishing such requirements (5). To evaluate implementation of these recommendations, a survey of 3,606 colleges and universities was conducted jointly by the CDC and ACHA in the fall of 1984 (6). The 1984 survey was conducted by state and local immunization program personnel in the 10 Public Health Service regions. In eight of these regions, data were obtained from more than 50% of colleges. In order to assess further progress, ACHA conducted a follow-up survey in the spring of 1986. For this survey, a questionnaire was mailed to the 3,210 U.S. colleges and universities registered with ACHA or the American Council of Education.

Comparative data from the 1984 and 1986 surveys are presented in Table 1. In 1984, 16% of 1,861 responding institutions required measles and rubella immunizations as a condition for attendance. Of the 3,210 colleges surveyed in 1986, 1,085 (34%) responded. Of those responding, 601 (55%) reported having a preadmission immunization requirement (PIR); 499 (45%) included both measles and rubella. In both surveys, there was considerable variation by region.

The 1984 survey did not collect information regarding enforcement of existing requirements; however, the 1986 survey did. Of the 601 colleges reporting a PIR, 305 (51%) placed a hold on first or second semester registration for noncompliers. Another 21% reported other sanctions including fines, withholding grades, suspension, and letters to the students or their parents from the Student Health Office or Dean's Office. Some prohibited dormitory residence, use of student health services, or participation in clinical work by students training in health professions.

Colleges without a PIR were asked whether they considered such a program important and why they did not have one. Of 403 schools responding, 253 (63%) felt that a PIR was important. The majority (62%) cited their general policy of not instituting special entrance requirements as their reason for not having a PIR. Twenty-six percent replied that they did not have adequate personnel to administer a program. Lack of access to a computerized data storage system was mentioned by 27%. The major barriers to implementation seemed to involve procedures rather than disagreement concerning the importance of the recommendation.

In the 1986 survey, colleges and universities were also asked about their policy regarding education and vaccination against hepatitis B infection. Twenty-four percent of respondents had a policy recommending hepatitis B vaccine for certain high-risk groups. These high-risk groups included male homosexuals, nursing students, medical students, dental students, other health care students, and foreign students from endemic areas. The survey did not assess the overall representation of these groups in the responding colleges. In general, in the majority ( 90%) of responding institutions, all categories of students had to bear the cost of the vaccine. Reported by: DS Smith, MD, M Collins, MD, University of Pennsylvania Student Health Service, Philadelphia, Pennsylvania. Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: During the past decade there has been a shift in focus at colleges and universities regarding the necessary content of a PIR. At first, the emphasis was on tetanus and diphtheria prophylaxis (7) as well as tuberculosis skin testing. As campuses continued to experience measles and rubella outbreaks with their potential for significant morbidity and even mortality (8), colleges began requiring documentation of immunity to measles and rubella, as well as to mumps, diphtheria, tetanus, and poliomyelitis (4). The recent emphasis on hepatitis B infection and acquired immunodeficiency syndrome (AIDS) has led many health care professionals to recommend that colleges require hepatitis B vaccination for those at risk and provide students with information on AIDS. On May 30, 1986, the ACHA Council of Delegates passed a resolution recommending that colleges educate their students at high risk for hepatitis B concerning their need to be vaccinated.

Since 5%-20% of young adults remain susceptible to measles and/or rubella, colleges have provided a receptive setting for the occurrence of outbreaks of these diseases. Of the more than 12.8 million persons attending American institutions (9), between 640,000 and 2.6 million susceptible persons could potentially be affected by PIRs. Despite nearly 2 decades of intensive public health efforts to immunize all schoolchildren, many students reach college age still susceptible to these diseases. Several factors have contributed to this situation. First, many in the current cohort of college students may have entered primary school before the adoption of state laws requiring proof of prior immunization and may not have been immunized (2). Many may have missed natural infection because naturally-occurring measles and rubella transmission have declined markedly (3). In addition, individuals vaccinated between 1963 and 1967 may have been immunized with killed measles virus vaccine, given further attenuated live measles vaccine in conjunction with immune globulin, or immunized before 1 year of age--all practices which have subsequently been found to produce inadequate long-term immunity in some individuals (10). Furthermore, the high rates of contact among college students in dormitories, lecture halls, and other college facilities increase the chances of transmission to susceptible students. Finally, introduction of disease by students returning from travel to endemic areas in foreign countries has played an important part in recent outbreaks (11).

Outbreaks of measles and rubella at colleges have been costly and have had a tremendous negative impact on student health and campus activities (12,13). An outbreak of measles at Principia College resulted in three deaths (8). A Boston University outbreak spread to Massachusetts Institute of Technology, Boston College, and Northeastern University in Boston (8) and was probably responsible for initiating an outbreak at Villanova University outside of Philhadelphia (13). Containment of an outbreak at Indiana University cost $225,000 (13).

Current efforts to deal with this problem have varied. Many schools resort to de facto outbreak control as their first strategy. Other schools have adopted their own internal PIR, with or without enforcement measures. A few states and other jurisdictions, notably the District of Columbia, Maine, Massachusetts, North Carolina, Puerto Rico, Rhode Island, and Virginia have extended their school immunization requirements to colleges and universities. The governing boards of state institutions in California, Florida, Mississippi, North Dakota, and South Dakota have adopted policies requiring proof of immunity for students registering in state-supported institutions. In the 1986 survey, about 85% of responding schools in states with a law in effect at the time of the survey (North Carolina, Massachusetts, Rhode Island*, and Mississippi) reported having PIRs. In contrast, 51% of schools in states and jurisdictions without a law had PIRs.

Data from recent rubella outbreaks suggest that review and enforcement of immunization requirements are important (12,14). In 1983-1985, there were 132 rubella cases in seven college outbreaks. Seventy-four percent of the patients had inadequate previous documentation of immunity to rubella. Three of the colleges had immunization requirements, but none had a mechanism for review or enforcement. In 1985, nearly two-thirds of measles cases on college campuses were reported among persons without adequate evidence of immunity.

Despite questions regarding comparability of the 1984 and 1986 surveys and the low response rates, the data suggest that there has been progress toward implementing comprehensive immunization review processes in colleges. Since voluntary vaccination programs are less effective than mandatory programs, further efforts to implement and enforce matriculation requirements for immunization are essential. Uniform state legislation mandating extending school immunization requirements to colleges would have significant impact on eliminating vaccine-preventable diseases from college campuses. In addition, future efforts should include other vaccine-preventable diseases, such

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