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

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 Conference: EveryONE Counts Anchorage, Alaska October 9, 2013 National Center for Immunization and Respiratory Diseases

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

Comparison of 20 th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases 20th Century 2012 Percent Disease Annual Morbidity † Reported Cases † † Decrease Smallpox 29,005 0 100% 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 0 100% 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.

Vaccine Coverage Rates Among Preschool-Aged Children: 1967 – 2012 Percent 100 HP 2020 Target * 80 DTP / DTaP(3+) † Hep B RV ¶ (3+) 60 PCV MMR(1+) Polio (3+) (4+) 40 Hep A <1% of toddlers had received no vaccines (2+) 20 Hib § Varicella (1+) 0 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 * 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.

Pneumonia hospitalizations declined after 7-valent Pneumococcal Conjugate Vaccine introduced in 2000 3000 Hospitalizations per 100,000 2500 2000 population 1997-9 2001-6 1500 2007-9 1000 500 0 <2 years 65+ years Griffin M et al NEJM 2013 DEPARTMENT OF HEALTH AND HUMAN SERVICES

Total rotavirus tests & the number testing rotavirus positive NREVSS laboratories, 2000‒2013 Vaccine Introduced 600 500 Total Tests No. No. Positive Results 400 Count 300 200 100 0 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 6/8/2013 Week 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

Declining Incidence of Total and Antibiotic Resistant Invasive Pneumococcal Disease in Children <5 years old with PCV13 25.0 <5 Overall Cases per 100,000 population <5 Antibiotic-resistant 20.0 15.0 12 10.0 6 5.0 PCV13 introduction 0.0 2008 2009 2010 2011 2012 HP2020 Target Year CDC Unpublished, Active Bacterial Core surveillance

>80 million Americans vaccinated in response to pandemic H1N1 influenza

Estimated Influenza Vaccination Coverage, Children 6 Months – 17 Years 100 NIS NHIS 90 HP 2020 Target 80 70 60 Percent 50 40 30 20 10 0 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 (seasonal) Source: CDC, National Immunization Survey (NIS), National Health Interview Survey (NHIS)

Estimated Influenza Vaccination Coverage, Healthcare Personnel* and Pregnant Women, Internet Panel Surveys 2009-10 (seasonal) 2010-11 2011-12 2012-13 100 90 92% of physicians were vaccinated in 2012/13 flu season 80 72 67 70 64 62 60 Percent 51 49 49 50 40 30 20 10 0 Healthcare Personnel Pregnant Women * HP 2020 Target is 90 percent for healthcare personnel

Personal Belief Exemptions in Kindergarteners, San Diego County, 2008 * * Courtesy of D. Sugerman et al.

MMWR August 2, 2013

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) *MMWR September 13, 2013 18

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

Measles, United States, 2001-2013* Importations by WHO Region 90 Unknown Western Pacific(WPR) 80 South East Asian(SEAR) 70 European(EUR) Number of Cases Eastern Mediterranean(EMR) 60 African(AFR) 50 American(AMR) 40 30 20 10 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Year *2013 case count preliminary as of September 14

Measles Epidemic in France

In the Fog

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

Reported pertussis incidence by age group: 1990-2011 100 Incidence rate 80 (per 100,000) <1 yr 1-6 yrs 60 7-10 yrs 11-19 40 20+ yrs 20 0 1990 1995 2000 2005 2011 Year SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System

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

Reported NNDSS pertussis cases: 1922-2012* 45,000 40,000 300,000 35,000 30,000 25,000 DTP 250,000 20,000 Number of cases 15,000 10,000 200,000 5,000 0 1990 1995 2000 2005 2010 150,000 Tdap 100,000 DTaP 50,000 0 1922 1930 1940 1950 1960 1970 1980 1990 2000 2010 Year *2012 data are provisional. SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service

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 quickly 3  Switch to aP vaccines is changing pertussis epidemiology  i.e. a problem of susceptibility despite vaccination  Waning immunity driving disease incidence 1 Clin Infect Dis. 2010 Aug 1;51(3):315-21. 2 Ped Infect Dis J 2009;28(2):152-153. 3 CDC. MMWR 2012;61(28);517-522.

Maximizing the Vaccination Program • Sustaining DTaP coverage • Increasing Tdap coverage • Vaccinating to protect infants

Hitting a Wall

Vaccination trends in 13-17 yr. olds, US, 2006-2012 90 ≥1 Tdap 80 ≥1 MCV 70 ≥1 HPV 60 females only Percent 50 ≥3 HPV 40 females only 30 20 ≥1 HPV males only 10 ≥3 HPV males only 0 2006 2007 2008 2009 2010 2011 2012 MMWR. August 30, 2013; NIS-Teen

Too Many Missed Opportunities! Actual v potential coverage if each vaccine was given whenever another teen vaccine was provided: NIS-Teen 2012 100 80 Healthy People 2020 Objectives Percent Vaccinated 60 93.3 Actual 92.8 92.6 88.5 40 Potentially Achievable 74.0 53.8 20 0 Td/Tdap MenACWY HPV-1 Vaccine HPV-1 coverage is among females only. Source: NIS Teen 2012; Slide courtesy Shannon Stokley (CDC/NCIRD/ISD)

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.

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

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

Where we want to be