Acting Assistant Secretary for Health Cristina Beato
chaired a focus area Progress Review on Immunization and Infectious
Diseases, the 12th in a series of assessments of Healthy People
2010. Dr. Beato noted that success in this area requires an
unusually close collaboration among the fields of science, research,
surveillance, information management, workforce training, education,
and communication. Just as important, achieving such success involves
partnerships between the public and private sectors, which must
be prepared to confront global issues that affect the ability to
control the spread of certain illnesses. In conducting the review,
Dr. Beato was assisted by staff of the Centers for Disease Control
and Prevention (CDC), which has the lead for this Healthy People
2010 focus area. Also participating were representatives of
other offices and agencies within the Department of Health and
Human Services.
The complete text for the Immunization and Infectious Diseases
focus area of Healthy People 2010 is available at www.healthypeople.gov/document/html/volume1/14immunization.htm.
The meeting agenda, data presentation (tables and charts), and
other briefing materials for the Progress Review can be found at www.cdc.gov/nchs/about/otheract/hpdata2010/fa14/immun.htm.
Data Trends
In opening his presentation on the status of objectives for Immunization
and Infectious Diseases, Edward Sondik, Director of CDC’s National
Center for Health Statistics, remarked that this focus area presents
a highly positive picture overall, with notable progress toward
many of the targets. Some of the lessons learned from successful
strategies here could very likely be applied to good effect in
other focus areas. An indication of the success of immunization
efforts is preliminary data for 2002 that show record lows in morbidity
for five of nine vaccine-preventable diseases—measles, mumps, polio
(0 cases), rubella, and tetanus (Obj. 14-1).
In 2002, the 2010 target of 90 percent coverage levels was met
or surpassed for four of seven recommended vaccinations of children
aged 19 to 35 months—Haemophilus influenzae type b (Hib),
hepatitis B, measles-mumps-rubella (MMR), and polio. Coverage for
pneumococcal conjugate vaccinations (for which no target has been
determined) showed a dramatic improvement in 2002 (Obj. 14-22).
In general, rates of vaccination coverage for this age group advanced
at a rapid pace over the past few years, and disparities among
population groups narrowed substantially. In contrast, efforts
to increase vaccination coverage rates for older people have been
less successful on the whole. In 2002, an estimated 66 percent
of adults 65 years of age and older had been vaccinated against
influenza during the preceding 12 months, compared with 64 percent
in 1998. The target is 90 percent coverage (Obj. 14-29a). Preliminary
data for 2002 show that 56 percent of adults 65 years of age and
older had at some time received pneumococcal vaccine, compared
with 46 percent in 1998 (target, 90 percent). Whereas coverage
rates for whites and blacks have risen in every year since 1998,
rates for Asians and Hispanics have fallen during the first years
of this decade (Obj. 14-29b).
The incidence of hepatitis A decreased from 11.2 new cases per
100,000 in 1997 to 2.9 per 100,000 (preliminary data) in 2002,
surpassing the target of 4.5 (Obj. 14-6). This remarkable decline
was spurred by the licensure of a new vaccine in 1995 and the issuance
of revised recommendations by the Advisory Committee on Immunization
Practices in 1996 and 1999. Hepatitis B incidence among people
aged 19 to 39 years decreased from an estimated 44.5 new cases
per 100,000 in 1990 to 13.94 per 100,000 in 2002, while among people
aged 40 and older, the rate decreased from 21.1 to 12.6 per 100,000
in the same timeframe (Obj. 14-3). Among people younger than 19
years of age, the incidence declined from 18.6 per 100,000 in 1990
to 1.5 in 2002, reflecting a particularly sharp downturn in the
years from 1998 onward. Among five racial/ethnic groups for whom
data were available, hepatitis B incidence in 2001 was highest
for blacks (more than 20 cases per 100,000 in all three age groups)
and second highest for American Indians/Alaska Natives (more than
15 per 100,000 in the three age groups).
Between 1998 and 2001, the incidence of new tuberculosis (TB)
cases in the total population decreased from 6.8 to 5.8 per 100,000,
a decline of 15 percent. The target is 1.0 case per 100,000 (Obj.
14-11). Of the five racial/ethnic groups, incidence was highest
for Asians and Pacific Islanders—34.9 per 100,000 in 1998, declining
by 12 percent to 30.8 per 100,000 in 2001. During that period,
the incidence declined by 20 percent for blacks (second highest)—from
17.4 to 13.7 per 100,000. Whites as a group came closest to the
target in 2001, with an incidence of 1.7 per 100,000, a decline
of 26 percent from 2.3 per 100,000 in 1998. The proportion of TB
patients who complete curative therapy within 12 months increased
from 74.0 percent in 1996 to 79.9 percent in 1999. All five racial/ethnic
groups were within 3 percentage points of the national proportion.
The target is 90 percent (Obj. 14-12).
Key Challenges and Current Strategies
In the presentations that followed the discussion of data, the
main themes were introduced by senior CDC staff members Walter
Orenstein (immunization), Stephen Ostroff (infectious diseases),
and Kenneth Castro (tuberculosis). Participants in the review identified
a number of obstacles to achieving the objectives and outlined
activities under way to meet these challenges, including the following:
- Resource Issues. In general, the closer the
approach to elimination of an infectious disease, the more difficult
it becomes to take the incremental final steps toward the goal.
Application of cost-effectiveness principles at that stage of
diminishing returns is misguided and can be self-defeating. For
example, when adjusted for inflation, Federal funds appropriated
for TB control programs have decreased in almost every year since
the mid-1990s, partly as a result of the relative success of
those efforts.
- Because of their low visibility in the public eye, longstanding
endemic infectious diseases face inherent difficulty competing
for funds and other resources with more dramatic recent arrivals,
such as SARS and West Nile virus.
- Preparation of action and contingency plans in advance of infectious
disease crises has helped the legislative branch to appropriate
funds quickly when these events occur.
- Childhood immunization is ranked topmost among 30 preventive
clinical services recommended by the U.S. Preventive Services
Task Force in its Guide to Clinical Preventive Services.
The procedure is estimated to produce direct savings of $10.5
billion and overall savings to society of $42 billion.
- Outreach Issues. Factors that depress levels
of vaccination coverage in adults include misinformation about
the efficacy of influenza vaccinations and ignorance of the existence
of vaccine against pneumococcal disease. Blacks and Hispanics
have significantly lower rates of immunization for influenza
and pneumococcal disease than other racial/ethnic population
groups.
- The Racial and Ethnic Adult Disparities Immunization Initiative
(READII) is a 2-year demonstration project being conducted by
CDC in four cities and the Mississippi Delta region to improve
influenza and pneumococcal vaccination rates for blacks and Hispanics
65 years of age and older.
- CDC has several campaigns under way to address issues of antibiotic
use and resistance:
- Get Smart: Know When Antibiotics Work is a national
advertising campaign aimed at instructing parents against the
overuse of antibiotics when treating colds and flu in their
children.
- The Campaign to Promote the Appropriate Use of Antibiotics develops
strategies and materials that will lead to changes in antibiotic
use and encourage formation of partnerships to harness the
resources of collaborating organizations.
- The Campaign to Prevent Antimicrobial Resistance promotes
strategies to reduce antimicrobial use among a variety of inpatient
populations and focuses on four goals—prevention of infection,
effective diagnosis and treatment, wise use of antimicrobials,
and prevention of transmission.
- Public Health Infrastructure Issues. A resurgence
of measles in 1990 and 1991 was a dramatic illustration of the
fallacy of ever considering an infectious disease completely
controlled. Positive results from this outbreak include the development
of infectious disease action plans by all states, greater funding
for infrastructure, and a redirecting of priority to the immunization
of children.
- Factors contributing to the unprecedented resurgence of TB
from the mid-1980s to 1992 included a deficient infrastructure;
the impact of HIV, immigration, and institutional outbreaks;
and the emergence of drug-resistant strains of TB. By 1993, corrective
actions led to a resumption in the declining trend in reported
cases, which had halted in 1984.
- Most cases of TB in this country now occur in people born outside
the United States. The countries that currently contribute the
greatest number of entrants with active TB are Mexico, Vietnam,
and the Philippines.
- Workforce Training Issues. CDC is working
with six schools of medicine and the American Medical Association
to develop a curriculum and standards for the diagnosis and treatment
of otitis media, an ear infection that is often overtreated with
antibiotics.
Approaches for Consideration
During the review, the following suggestions were made for steps
that could be taken to bring about further progress against infectious
diseases:
- Outreach. Work with the states to lengthen
the period of time during the school year when vaccinations are
given to schoolchildren.
- Strive to increase access to vaccination for younger children
who are at high risk for hepatitis B.
- Place greater emphasis on immunization of adolescents and ensure
that vaccination against meningococcal meningitis is available
to them.
- Vaccine Development and Manufacture. Increase
efforts to develop vaccines against TB and hepatitis C.
- Seek new ways to provide incentives for manufacturers to increase
the supply and availability of vaccines.
- Public Health Infrastructure. Strengthen the
infrastructure in existing public health and correctional settings
for delivering hepatitis A and hepatitis B vaccine and for hepatitis
C testing and referral for treatment.
- Prepare action and contingency plans for the management of
infectious disease crises in partnership with those who will
implement them and can help mobilize resources. Use lessons learned
from such crises to identify necessary changes in the permanent
infrastructure for responding to infectious disease outbreaks.
- Create better ongoing and integrated infectious disease surveillance
systems that can provide regional and local data capable of driving
political action.
Contacts for information about Healthy People 2010 focus
area 14 Immunization and Infectious Diseases:
- Office of Disease Prevention and Health Promotion (coordinator
of the Progress Reviews)Debra Nichols, dnichols@osophs.dhhs.gov (liaison
to the focus area 14 workgroup)
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Cristina V. Beato, M.D.
Acting Assistant Secretary for Health
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