National Immunization Update Where we are vs. where we want to be - - PowerPoint PPT Presentation

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National Immunization Update Where we are vs. where we want to be - - PowerPoint PPT Presentation

Mar 25, 2024 312 likes •810 views

National Immunization Update Where we are vs. where we want to be Anne Schuchat, MD RADM, US Public Health Service Assistant Surgeon General Director, National Center for Immunization and Respiratory Diseases 2013 Alaska Immunization

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2013 Alaska Immunization Conference: EveryONE Counts Anchorage, Alaska October 9, 2013

National Center for Immunization and Respiratory Diseases

National Immunization Update

Where we are vs. where we want to be

Anne Schuchat, MD

RADM, US Public Health Service Assistant Surgeon General Director, National Center for Immunization and Respiratory Diseases

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Immunization in the US

  • Most vaccine-preventable diseases at record lows
  • Achieved & sustained high childhood

immunization

  • Reduced disparities in childhood coverage
  • Introduced multiple new vaccines
  • Improved production and suppliers of influenza

vaccine

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Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases

Disease 20th Century Annual Morbidity† 2012 Reported Cases † † Percent Decrease

Smallpox 29,005 100% Diphtheria 21,053 1 > 99% Measles 530,217 55 > 99% Mumps 162,344 229 > 99% Pertussis 200,752 48,277 76% Polio (paralytic) 16,316 100% Rubella 47,745 9 > 99% Congenital Rubella Syndrome 152 2 99% Tetanus 580 37 94% Haemophilus influenzae type b 20,000 30* > 99%

†Source: JAMA. 2007;298(18):2155-2163 † † Source: CDC. MMWR January 4, 2013;61(52);ND-719-ND-731. (provisional week 52 data)

* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 13 cases of Hib are estimated to have occurred among the 210 reports of Hi (< 5 years of age) with unknown serotype.

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Vaccine Coverage Rates Among Preschool-Aged Children: 1967 – 2012

20 40 60 80 100 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 Percent

Hep A (2+) DTP / DTaP(3+)† MMR(1+) Hib§

HP 2020 Target*

Hep B (3+) Polio (3+) Varicella (1+) PCV (4+) RV¶

* Target 80% for Rotavirus and 85% for Hep A, † DTP/DTaP (3+) is not a Healthy People 2020 objective.. § Hib reflects 3+ doses thru 2008, and Full Series (3 or 4 doses per vaccine type) 2009 onward Note: USIS and NHIS children: 24-35 mos of age. NIS children 19-35 mos of age. Source: USIS (1967-1985), NHIS (1991-1993) CDC, NCHS and NIP, and NIS (1994-2012), CDC, NIP, NCHS and NCIRD; No data from 1986-1990 due to cancellation of USIS because of budget reductions.

<1% of toddlers had received no vaccines

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Pneumonia hospitalizations declined after 7-valent Pneumococcal Conjugate Vaccine introduced in 2000

Griffin M et al NEJM 2013

500 1000 1500 2000 2500 3000 <2 years 65+ years Hospitalizations per 100,000 population 1997-9 2001-6 2007-9

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100 200 300 400 500 600 7/8/2000 7/8/2001 7/8/2002 7/8/2003 7/8/2004 7/8/2005 7/8/2006 7/8/2007 7/8/2008 7/8/2009 7/8/2010 7/8/2011 7/8/2012 Count Week

Total Tests No.

  • No. Positive Results

Vaccine Introduced

Total rotavirus tests & the number testing rotavirus positive NREVSS laboratories, 2000‒2013

6/8/2013

Between 2008 and 2012:

  • 200,000-250,000 hospitalizations prevented among children < 5 years
  • > $900 million dollars saved in direct medical costs from averted rotavirus-related

hospitalizations and ED visits

Sources: National Respiratory and Enteric Virus Surveillance System and the New Vaccine Surveillance Network

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12 6

0.0 5.0 10.0 15.0 20.0 25.0 2008 2009 2010 2011 2012 HP2020 Target

Cases per 100,000 population Year <5 Overall <5 Antibiotic-resistant

Declining Incidence of Total and Antibiotic Resistant Invasive Pneumococcal Disease in Children <5 years old with PCV13

PCV13 introduction CDC Unpublished, Active Bacterial Core surveillance

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>80 million Americans vaccinated in response to pandemic H1N1 influenza

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Estimated Influenza Vaccination Coverage, Children 6 Months – 17 Years

Source: CDC, National Immunization Survey (NIS), National Health Interview Survey (NHIS)

10 20 30 40 50 60 70 80 90 100 2007-08 2008-09 2009-10 (seasonal) 2010-11 2011-12 2012-13 Percent NIS NHIS

HP 2020 Target

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Estimated Influenza Vaccination Coverage, Healthcare Personnel* and Pregnant Women, Internet Panel Surveys

62 64 49 67 49 72 51 10 20 30 40 50 60 70 80 90 100 Healthcare Personnel Pregnant Women Percent 2009-10 (seasonal) 2010-11 2011-12 2012-13

* HP 2020 Target is 90 percent for healthcare personnel

92% of physicians were vaccinated in 2012/13 flu season

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Personal Belief Exemptions in Kindergarteners, San Diego County, 2008 *

* Courtesy of D. Sugerman et al.

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MMWR August 2, 2013

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Measles Outbreaks*, United States, 2013

  • 77% of 159 year-to-date cases were outbreak-

associated

  • 8 total outbreaks, including largest since 1996
  • 84% of US residents cases were unvaccinated

– 92 (79%) had philosophic objections to vaccine – 15 (13%) <12 mos (not eligible to be vaccinated)

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*MMWR September 13, 2013

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On March 13, 2013, an intentionally unvaccinated adolescent aged 17 years returned to New York City from London, United Kingdom, while infectious with measles.

Measles sles out utbreak break tied to Te Texas s megachurch achurch sicke kens ns 21

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Measles, United States, 2001-2013* Importations by WHO Region

10 20 30 40 50 60 70 80 90 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Number of Cases Year

Unknown Western Pacific(WPR) South East Asian(SEAR) European(EUR) Eastern Mediterranean(EMR) African(AFR) American(AMR)

*2013 case count preliminary as of September 14

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Measles Epidemic in France

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In the Fog

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Slide: courtesy of Kathleen Winter, source: California Department of Public Health

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Reported pertussis incidence by age group: 1990-2011

20 40 60 80 100 1990 1995 2000 2005 2011

Incidence rate (per 100,000) Year

<1 yr 1-6 yrs 7-10 yrs 11-19 20+ yrs

SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System

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Waning protection from Dtap shots in early childhood

  • 92-98% vaccine

effectiveness (VE) w/in 3 years of fifth dose

  • VE 71% by five years

after fifth dose

L Misegades, JAMA November 28, 2012

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50,000 100,000 150,000 200,000 250,000 300,000

1922 1930 1940 1950 1960 1970 1980 1990 2000 2010

Number of cases Year

Reported NNDSS pertussis cases: 1922-2012*

DTP

5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 1990 1995 2000 2005 2010

Tdap DTaP

SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service *2012 data are provisional.

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Pertussis Summary – “It’s Complicated!”

 Pertussis incidence has increased since 1980s  Resurgence of childhood disease despite high DTaP coverage

  • Excellent initial vaccine effectiveness
  • Moderate and immediate waning of immunity

 Re-emergence of adolescent disease

  • Tdap effectiveness about 70%1, 2, duration of protection unknown
  • Tdap boost in DTaP recipients may wane more quickly3

 Switch to aP vaccines is changing pertussis epidemiology

  • i.e. a problem of susceptibility despite vaccination
  • Waning immunity driving disease incidence

1Clin Infect Dis. 2010 Aug 1;51(3):315-21. 2Ped Infect Dis J 2009;28(2):152-153.

  • 3CDC. MMWR 2012;61(28);517-522.
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Maximizing the Vaccination Program

  • Sustaining DTaP coverage
  • Increasing Tdap coverage
  • Vaccinating to protect infants
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Hitting a Wall

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Vaccination trends in 13-17 yr. olds, US, 2006-2012

  • MMWR. August 30, 2013; NIS-Teen

≥1 Tdap ≥1 MCV

≥3 HPV

females only

10 20 30 40 50 60 70 80 90 2006 2007 2008 2009 2010 2011 2012 Percent ≥1 HPV

females only

≥1 HPV

males only

≥3 HPV

males only

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Too Many Missed Opportunities!

Actual v potential coverage if each vaccine was given whenever another teen vaccine was provided: NIS-Teen 2012

88.5 74.0 53.8 93.3 92.8 92.6

20 40 60 80 100 Td/Tdap MenACWY HPV-1 Percent Vaccinated Vaccine Actual Potentially Achievable

Healthy People 2020 Objectives

HPV-1 coverage is among females only. Source: NIS Teen 2012; Slide courtesy Shannon Stokley (CDC/NCIRD/ISD)

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Top 5 reasons* for not vaccinating teen, among parents with no intention to vaccinate in the next 12 months, NIS-Teen 2012

Parents of girls Parents of boys Not needed or necessary 19.0% Not recommended 23.9% Not recommended 15.0% Not needed or necessary 22.3% Safety concern/side effects 14.2% Lack of knowledge 17.5% Lack of knowledge 13.6% Not sexually active 8.6% Not sexually active 11.5% Child is male 5.4%

*Response categories are not mutually exclusive.

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Interpretation of HPV Uptake Situation

 Plateau in HPV uptake in girls is persisting  Provider “hesitancy” (voicing weak recommendations)

  • “Won’t go to the mat for this one”
  • Possible reasons: haven’t bought in to rationale for 11-12 yr

timing, cost, competing priorities, communication skills

 Parental attitudes appear open to influence of

providers – which requires clinicians to be convinced , confident and communicating effectively

 System interventions (e.g., HEDIS, AFIX) won’t succeed

without clinician commitment

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‘The ultimate victory will depend on the hearts and minds...”

Lyndon Baines Johnson

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Where we want to be

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Tools for Clinicians and Parents

 Provider Resources for Vaccine Conversations with

Parents

  • www.cdc.gov/vaccines/conversations

 Health Care Professional Home Page

  • www.cdc.gov/vaccines/hcp

 “Get the Picture” Childhood Video

  • www.youtube.com/user/CDCStreamingHealth

 Public awareness campaigns (Niiw, NIVW)

  • Radio, TV , print PSAs
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www.cdc.gov/vaccines

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Where we want to be: Reaching the moon

Setting and Achieving Ambitious Goals

I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him safely to the earth.

  • President John F. Kennedy, May 25, 1961
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* VTrckS

Doctor’s offices

* Barcodes Health Departments and Immunization Information System

Modernizing Immunization Practice through IT Investments

E-health records

4 Focus Areas *

* Clinical Decisions * Interoperability

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Where we want to be: The Promised Land

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Immunization and Equity

 ~25 years ago resurgent measles epidemics in LA,

Houston, and other US cities led to recognition that many poor children were missing vaccines due to lack of insurance

 The Vaccines for Children Program, implemented

in 1994, has nearly eliminated racial, ethnic, and economic disparities in infant immunization in America

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Today, more than 80 percent of the world’s children receive vaccines – I believe around 82 per cent as measured by the 3rd dose of the DTP3 vaccine. That’s around four out of every five children.

But what of the fifth child – the child we don’t reach?

Tony Lake UNICEF Executive Director

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Same children are chronically missed

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In 2012, the world got closer than ever to polio eradication

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# sites w/ migrants: 162,000 # children < 5 yrs in sites : ~ 4.2 M

Mapping and reaching migrants for polio eradication in India, 2011

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The Distance Between

where we are and where we want to be

  • Knowing that we aren’t there yet is the first step
  • Figuring out where we should be going is next
  • Measuring our progress along the way is essential
  • Together we can get there
  • Together we will get there