Immunization and Infectious Diseases

Dr. Slobodkin stated that he felt adult immunization, primarily related to influenza and pneumococcal disease, had been shortchanged in these Healthy People 2010 objectives. For example, although these are responsible for most vaccine-preventable disease deaths, there are no process objectives proposed. He noted that pediatric vaccine-preventable disease programs were effective, and influenza efforts were significantly improving, but pneumococcal disease was not close to where it should be. He suggested that the adult immunization proposals be more ambitious by including process objectives.

Dr. Slobodkin provided an article, "Demonstration of the Feasibility of Emergency Department Immunization Against Influenza and Pneumococcus," as evidence to help justify the need for additional adult immunization objectives. He noted that at Cook County Hospital, flu/pneumococcal immunization rates are less than 10%. The Hospital sees about 120,000 adults a year. The American College of Emergency Physicians has passed a resolution noting that these situations are missed opportunities related to adult immunization. He said he would fax a copy of the resolution to CDC. Again, he suggested that Healthy People should further address adult immunization. He did not feel that Objectives 22.2 and 22.24 adequately addressed adult immunization. Similarly, Ms. Virginia Burggraf, D.N.S.C., R.N., American Nurses Association, added that we should not miss the opportunity to vaccinate. She suggested that demonstration projects to address this problem are required. Ms. Chris Grant of Pasteur Merieux Connaught also suggested that more attention be paid to adult immunization, especially influenza immunization. For example, she noted that coverage rates for high risk adults were "woefully inadequate", and there was also a need to immunize healthy adults.

On a related matter, Dr. Slobodkin suggested a broadening of immunization registries to include adults. He recognized that registries are being designed only to cover children now, but asked why registries couldn't be adjusted to include adult hepatitis B and pneumonia vaccination records. He added that he understood the civil liberties and privacy issues, but suggested an expansion of registries. Ms. Burggraf also suggested that by 2005 registry efforts should broaden their scope to include adult immunizations.

He also noted that he did not see a section on immunization of providers. He suggested that a high percentage of medical care providers be immunized against vaccine-preventable diseases.

He also noted that, as these are the individuals that may first see people with these diseases, there is a moral obligation that providers be protected against these diseases.

Ms. Burggraf suggested that rotavirus and Lyme disease vaccines be added to the Objective 22.21. She understood that rotavirus could be difficult to reach a 90% goal due to the seasonality of the disease and need for the vaccine primarily during certain periods. It was suggested that possibly this could be clarified by the 2005 mid-course correction.

Ms. Grant had four suggestions. These were:

Healthy People 2010 Objectives should highlight new vaccines that will be available over the next decade. For example, there should be a routine meningitis vaccine recommendation for the year 2010. It was noted that Chapter 22, Objective 21, has a footnote "d" which notes that "This series will change as new vaccines are incorporated."

She acknowledged that the statement is appropriate, but indicated that more emphasis than a footnote should be focused on this matter. Ms. Burggraf agreed with this suggestion.

While the Immunization and Infectious Disease Chapter should maintain an emphasis on children, there should be more attention given to adults and adolescents. For example, the chapter could be organized by "Pediatric/Adolescent/Adult." In the beginning of the Chapter, a broader definition of providers should be incorporated. For example, as noted by Dr. Slobodkin and Ms. Jann Hinkle of the American Pharmaceutical Association, it should be noted that emergency room physicians, pharmacists, and possibly others could provide vaccinations. She noted that she was not suggesting another Objective, but was suggesting some narrative in Chapter 22 to help broaden what people currently consider to be a "provider".

Ms. Grant suggested that Objective 22.33 relating to Vaccine Associated Paralytic Polio (VAPP) be reconsidered in light of the movement to an all-IPV schedule. She noted that by the time that the Healthy People document is published in January 2000, there will be an all-IPV schedule recommended in the US. This schedule in itself will eliminate VAPP. Thus, this objective will be outdated at the start of the decade. She suggested that this objective be revised, noting that recommendations exist that could eliminate VAPP now, and that the goal to eliminate VAPP be moved up to the year 2005.

Ms. Grant also made the point that there should be a way that each objective makes a general statement about how the individual reader can make a practical step toward achieving or helping to achieve the objective.

Ms. Hinkle also suggested that the definition of provider be expanded, as noted previously. She stated that in 26 States, pharmacists can give immunizations. Pharmacists provide an excellent opportunity to facilitate the provision of vaccines. For example, many rural counties in the US do not have a physician, but virtually all have pharmacists. An on-going demonstration project between CDC and West Virginia is focusing on this issue. She summarized that the list of potential providers in the Chapter 22 narrative be expanded to include pharmacists.

Ms. Greene raised a point about the need for school nurses. Some general discussion ensued. Dr. Burton Wilkie, Director, Division of Health Surveillance, Vermont Department of Health, also added that there are now fewer school nurses, especially in private schools. No particular recommendation for modifying the Objectives was made regarding this issue.

Ms. Green commented on the need for educating practitioners and consumers on the appropriate use of antibiotics. She mentioned a project out of Johns Hopkins which is focusing on schools and health educators as target areas for expanding understanding on the appropriate and judicial use of antibiotics. Conversation focused on the need to change our cultures present paradigm concerning use of antibiotics even though an antibiotic may not be the appropriate therapy choice.

Dr. Slobodkin, speaking as an emergency room physician said that parents don't really care about the "down-the-road" effects of antibiotic overuse and misuse. He said that effective and appropriate placebos need to be developed so that parents can feel like their children have received treatment. Related to Objective 28, it was also commented that information needs to be disseminated to providers and patients about correct therapies for the "common cold".

Dr. Wilcke pointed out five focus areas that need to be addressed if we are to effectively deal with the issue of antimicrobial resistance. Those areas are:

1. Improve and put in place surveillance systems
2. Convince practitioners to stop misusing antimicrobials
3. Bring vetenarians into the discussion
4. Close the gaps in laboratory testing of antimicrobial resistance
5. "Public Health" has to find a way to support state laboratories because there are no requirements or funding for state laboratories to report antimicrobial resistance.
6. Monitoring trends is not a cost priority for state laboratories

Nurse/EMT training curriculums need to be accessed to determine whether they are receiving training in emergency response to bio-terrorism. It should be a priority to ensure that they are receiving strong training in emergency response to bio-terrorism. Dr. Slobodkin commented that any funds spent on infrastructure for anti bio-terrorism measures must be looked at in terms of the cost-benefit. For example, anthrax would be devastating, but it is questionable whether any prevention plan would help. The question was also asked whether an infrastructure objective on bio-terrorism would be in the 2010 document.