CSTE ANNUAL MEETING CSTE POSITION STATEMENT 1998-ID-9  COMMITTEE: Infectious Disease TITLE: Varicella Surveillance and Control ISSUE: Varicella vaccine was licensed in March 1995 and has been available through the Vaccines for Children program (VFC) in most states since at least January 1997. Immunization levels of young children are now rapidly increasing. Unlike for other vaccine-preventable diseases of childhood against which vaccination is routinely recommended, most states do not have systematic surveillance to evaluate the ongoing impact of vaccination on varicella morbidity, nor is there a timely and sensitive national surveillance system for varicella morbidity. Recent investigations of the use of varicella vaccine to control outbreaks have been promising, although further studies are needed. Explosive and often prolonged outbreaks of varicella continue to occur in a variety of settings, complicated by presence of immunosuppressed persons, concurrent Group A Streptococcal (GAS)infection, and/or susceptible adults and result in preventable severe morbidity and deaths. No guidance yet exists for state and local immunization programs on the aggressiveness with which reported outbreaks should be investigated and controlled. Allowing such outbreaks to run their natural course is no longer acceptable and is inconsistent with the principles underlying the recommendations to routinely vaccinate all infants and susceptible children and high-risk adults. Guidance is needed and publicly funded vaccine needs to be available to support control. Outbreaks in day care centers (DCC) and schools carry the potential for exposure of many persons and can result in severe morbidity and death, particularly in the setting where virulent GAS strains are circulating. Such outbreaks are preventable with systematic vaccination of DCC and school enterers, yet few states have begun a process to require DCC and school entry vaccination against varicella. POSITION TO BE ADOPTED: Surveillance CSTE recommends that: 1. The National Immunization Program (NIP) - Centers for Disease Control and Prevention (CDC) strongly encourage all states as part of their core federal immunization funding, to carry out some form of ongoing systematic morbidity surveillance to monitor the impact of varicella vaccination on the incidence of varicella. Although states are encouraged to eventually establish individual case reporting systems, current resources may limit the potential to do so at this time. Until either resources are available or incidence drops substantially, acceptable forms of such surveillance may include aggregate case reporting, hospital discharge data review, sentinel systems (e.g., physicians/health maintenance or managed care organizations/school systems), or appropriately designed random digit dialing surveys. 2. At least annually, CDC-NIP collect the results of state-based systematic varicella surveillance efforts and include them in an annual composite national report on trends in varicella occurrence, until such time as varicella becomes a condition included in the National Public Health Surveillance System (NPHSS).  3. As soon as it is operationally feasible, each state adopt an individual or statewide aggregate varicella case reporting system. 4. CDC-NIP work with CSTE to develop varicella surveillance guidelines for the implementation of individual case reporting by states and to identify associated funding needs. 5. Varicella be considered to be included in the NPHSS when either an individual case reporting system or a statewide aggregate reporting system has been implemented in the majority of states. 6. CDC, in concert with the Association of Public Health Laboratories (APHL), develop the appropriate national laboratory capacity to support present and future surveillance and diagnostic needs including support of outbreak investigations, development and standardization of sensitive screening tests for immunity, development and support of molecular epidemiologic methods and their application to support national surveillance needs. Control CSTE recommends that: 1. States respond to reported varicella outbreaks by encouraging and supporting control efforts to include provision of patient/parent and health care provider education materials and provision of vaccine necessary to control the outbreaks to the extent permitted by VFC and other vaccine purchase funding.  2. CDC, in collaboration with CSTE and state immunization programs, should develop and disseminate recommendations for varicella outbreak response and control in day care centers, schools and other institutional settings and model educational materials that could be used as part of an outbreak response. 3. CDC encourage use of VFC vaccine for outbreak control and develop a special supplemental varicella vaccine purchase fund to support outbreak control in settings where most affected persons are not VFC-eligible.  4. By 1999, states begin the process of requiring varicella vaccine for daycare and school entry, and that CDC monitor the extent to which such efforts have been initiated and are successful.  BACKGROUND AND JUSTIFICATION: In March 1998, CDC-NIP sponsored a meeting on varicella surveillance to describe its current status and future directions. Consensus was achieved that since federally funded varicella vaccine is being provided to all states for universal immunization of infants and susceptible children through adolescence, each state should be accountable for monitoring the impact of that vaccine on varicella incidence. There was also consensus that there should be national surveillance for vaccine impact on morbidity and that varicella should be made nationally notifiable in the near future. There was not consensus on when this should happen and whether national surveillance during the initial build-up of immunization levels should be dependent on varicella being a nationally notifiable disease. Recent outbreak investigations suggest that varicella vaccine is highly efficacious at limiting and controlling outbreaks of varicella, although more data are needed. Concurrent outbreaks of varicella and Group A streptococcal disease among children and varicella among groups of persons some of whom are immunosuppressed have caused substantial morbidity and mortality. At the March meeting, there was consensus that it is no longer acceptable to allow recognized outbreaks of varicella to continue. It is also unacceptable to not actively encoura ge routine day care and school immunization against varicella. Correspondingly, it is necessary to have firmer national guidance to encourage outbreak control and routine immunization of children entering collective settings. COORDINATION WITH OTHER ORGANIZATIONS: Agencies for Response: National Immunization Program, CDC  National Center for Infectious Diseases, CDC Agencies for Information: Association of State and Territorial Health Officials (ASTHO) Association of Public Health Laboratories (APHL) CONTACT PERSON: James Hadler, MD, MPH State Epidemiologist Connecticut Department of Public Health 410 Capitol Avenue, PO Box 340308 Hartford, CT 06134-0308 Phone: (860) 509-7995  E-mail: jlh7@wonder.em.cdc.gov