In the 10th session in the second series of assessments of
Healthy People 2010, ADM John O. Agwunobi, Assistant Secretary for
Health, chaired a focus area Progress Review on Immunization and Infectious
Diseases. He was assisted by staff of the lead agency for this
Healthy People 2010 focus area, the Centers for Disease Control and
Prevention (CDC). Also participating in the review were representatives
from other U.S. Department of Health and Human Services offices and
agencies. ADM Agwunobi observed that, since the first-round Progress
Review earlier in the decade, events such as the emergence of the threat of
pandemic influenza had underscored the need to achieve and maintain high levels
of preparedness against the spread of infectious diseases. Topics
selected for special attention at the Progress Review included coverage status
for recommended vaccinations in young children, invasive pneumococcal
infections, Lyme disease, hepatitis B in adults, the incidence of new cases of
tuberculosis, and antibiotics prescribed for ear infections and for the common
cold.
The complete November 2000 text for the Immunization and
Infectious Diseases focus area of Healthy People 2010 is available
online at www.healthypeople.gov/document/html/volume1/14immunization.htm.
Revisions to the focus area chapter that were made after the January 2005
Midcourse Review are at www.healthypeople.gov/data/midcourse/html/focusareas/fa14toc.htm.
Some more recent data used in the Progress Review for this focus areas
objectives and their operational definitions can be accessed at wonder.cdc.gov/data2010.
For comparison, the report on the first-round Progress Review (held on August
20, 2003) is archived at www.healthypeople.gov/data/2010prog/focus14/2003fa14.htm.
The meeting agenda, tabulated data for all focus area objectives, charts, and
other materials used in the Progress Review can be found at a companion site
maintained by the CDC National Center for Health Statistics (NCHS): www.cdc.gov/nchs/about/otheract/hpdata2010/focusareas/fa14-immun2.htm.
Data Trends
In his overview of data for the focus area, Richard Klein of
the NCHS Health Promotion Statistics Branch noted that, of the more than 80
Healthy People 2010 objectives and subobjectives for Immunization and
Infectious Diseases, by far the majority had met or were moving closer to their
targets. Exceptions to this trend toward improvement include objectives
and subobjectives for Lyme disease, pertussis, and penicillin-resistant
pneumococcal infections in older adults. Progress in reducing morbidity
and mortality from infectious diseases in the United States is particularly
impressive when the situation is viewed over a longer time span. With one
exception (pertussis, by 83 percent), new cases of 10 diseases for which a
vaccine was developed prior to 1990 were reduced by 98 percent or more between
the period before vaccine introduction and 2005. Currently, vaccines are
available to protect children against 16 diseases. (For a list of these,
follow the link www.cdc.gov/vaccines/recs/schedules/downloads/child/2007/child-schedule-color-press.pdf.)
Seven of the most widely used vaccines are estimated to have prevented more
than 14 million cases of disease and more than 33,000 deaths over the lifetime
of children born in any given year. Such vaccination also resulted in
annual cost savings of $9.9 billion in direct medical costs and $33.4 billion
in indirect costs. Despite these advances, infectious diseases account
for 18 percent of all physician visits each year and exact a toll in treatment
costs and lost productivity that exceeds $120 billion each year. With
regard to mortality, pneumonia/influenza is the eighth leading cause of death
in the United States. Mr. Klein then examined in greater detail the
objectives selected for highlighting during the Progress Review.
(Obj. 14-3): New cases of hepatitis B
among adults aged 19 to 24 years decreased from a rate of 18.5 per 100,000
standard population in 1997 to 5.4 per 100,000 in 2005 (target, 1.8 per
100,000). Among adults aged 25 to 39 years, new cases decreased from 20.5
per 100,000 in 1997 to 10.2 per 100,000 in 2005 (target, 5.2 per
100,000). Among adults aged 40 years and older, new cases decreased from
14.7 per 100,000 in 1997 to 5.4 per 100,000 in 2005 (target, 3.7 per
100,000). In 2005, among five racial and ethnic populations for which
data were available, non-Hispanic blacks had by far the highest rate of new
cases of hepatitis B in each group: 10.2 per 100,000 among persons aged
19 to 24 years (compared with 38.3 per 100,000 in 1997); 16.6 per 100,000 among
persons aged 25 to 39 years (compared with 34.2 per 100,000 in 1997); and 9.1
per 100,000 among persons aged 40 years and older (compared with 27.5 per
100,000 in 1997). The other racial and ethnic populations for which data
were available are American Indians/Alaska Natives, Asians/Pacific Islanders,
Hispanics, and non-Hispanic whites.
(Obj. 14-5): New cases of invasive
pneumococcal infections among children aged less than 5 years decreased from a
rate of 77 per 100,000 in 1997 to 21 per 100,000 in 2005, surpassing the target
of 46 per 100,000. The 2005 rate for black children aged less than 5
years was 38 per 100,000, compared with 18 per 100,000 for white children aged
less than 5 years. The 1997 rates for those two groups were 155 per
100,000 and 63 per 100,000, respectively. New cases of invasive
pneumococcal infections among adults aged 65 years and older decreased from a
rate of 62 per 100,000 in 1997 to 40 per 100,000 in 2005, surpassing the target
of 42 per 100,000. The 2005 rate for black adults aged 65 years and older
was 51 per 100,000, compared with 39 per 100,000 for white adults aged 65 years
and older. The 1997 rates for those two groups were 84 per 100,000 and 61
per 100,000, respectively.
(Obj. 14-8): In the 10 reference
states where it is endemic, Lyme disease increased from a 5-year average annual
rate of 23.0 new cases per 100,000 in 19951999 to 31.6 per 100,000 in
20012005. The target is 9.7 per 100,000.
(Obj. 14-11): New cases of
tuberculosis (TB) decreased from a rate of 6.6 per 100,000 in 1998 to 4.8 per
100,000 in 2005. The target is 1.0 per 100,000. By race and
ethnicity, the 2005 rates per 100,000 were as follows: non-Hispanic
whites, 1.3; American Indians/Alaska Natives, 5.9; Hispanics, 9.5; non-Hispanic
blacks, 10.9; and Asians, 25.7.
(Obj. 14-18): Courses of antibiotics
prescribed for ear infections in children less than 5 years of age decreased
from a rate of 69 per 100 in 19961997 to 47 per 100 in 20042005,
surpassing the target of 56 per 100. Over that time span, decreases were
registered for black, white, female, and male children less than 5 years of
age, the 20042005 prescription rates per 100 for which were as
follows: blacks, 39; whites, 51; females, 44; and males, 51.
(Obj. 14-19): Courses of antibiotics
prescribed for the sole diagnosis of the common cold decreased from a rate of
2,535 per 100,000 in 19961997 to 1,376 per 100,000 in
20042005. The target is 1,268 per 100,000. The 20042005
prescription rates per 100,000 for selected population groups were as
follows: blacks, 1,029; whites, 1,370; females, 1,428; and males,
1,322.
(Obj. 14-22): The target is 90
percent for this objective to achieve and maintain effective vaccination levels
for universally recommended vaccines among children aged 19 to 35 months.
In 2005, coverage levels for specific vaccines were as follows: 4 doses
(4+) diphtheria-tetanus-acellular pertussis (DTaP), 86 percent; 3+
Haemophilus influenzae type b (Hib), 94 percent; 3+ hepatitis B (hep
B), 93 percent; 1+ measles-mumps-rubella (MMR), 92 percent; 3+ polio, 92
percent; 1+ varicella, 88 percent; and 4+ pneumococcal conjugate, 54
percent.
(Obj. 14-24a): Among children aged 19
to 35 months, 81 percent in 2005 had received certain vaccines (DTaP, polio,
MMR, Hib, hep B) at their recommended dosages. This marks an increase
from 73 percent in 1998 and surpasses the target of 80 percent. By 2005,
disparities in coverage for these vaccines among Hispanic, non-Hispanic white,
and non-Hispanic black children in this age group had been eliminated or
reduced to within a few percentage points.
Key Challenges and Current Strategies
In presentations that followed the data overview, the
principal themes were introduced by senior staff of CDCs Coordinating
Center for Infectious DiseasesRADM Anne Schuchat, Director, National
Center for Immunization and Respiratory Diseases; Rima Khabbaz, Director,
National Center for Preparedness, Detection, and Control of Infectious
Diseases; and Kevin Fenton, Director, National Center for HIV/AIDS, Viral
Hepatitis, STD, and TB Prevention. Their statements and briefing
materials provided to Progress Review participants for later discussion
identified a number of barriers to achieving the objectives, as well as
activities under way to meet these challenges, including the following:
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Although government purchases (local, state, and
Federal) account for nearly 55 percent of all childhood vaccine doses
distributed, most of the Nations childrenincluding the
hard-to-reach populations, underinsured, or poor children eligible to receive
vaccine at no costreceive their vaccine through a private
physicians office. Some physicians continued participation in
the childhood immunization system is challenged by their perception of
insufficient reimbursements for vaccine administration and the initial expense
of stocking a sufficient inventory of vaccines needed to fully vaccinate the
child patients in their practice.
-
Adolescents generally do not seek out preventive health
care, usually visiting a doctor only when they are sick. Many adolescents
obtain episodic health care from providers in varied settingsfor example,
gynecologists offices and emergency departmentsthat have rarely
offered routine vaccination services to adolescents. Unlike young
children, who receive preventive care more frequently, adolescents often do not
have an identified medical home, making it difficult for healthcare
providers to promote vaccination among them.
-
While infant and childhood immunization programs for
hepatitis B have been successful in dramatically lowering infection rates among
children less than 19 years of age, hepatitis B vaccine coverage is lowest for
adults with behavioral risks. In 2005, approximately 95 percent of the
cases of acute disease caused by the hepatitis B virus were among adults.
Barriers to hepatitis B vaccination in adults include the cost of vaccine, some
providers time constraints and/or lack of awareness, and patient
non-adherence to the three-dose schedule.
-
The 13,767 new cases of TB in 2006 represent less than
half of the persons who are evaluated for TB before the case count is
finalized. For every 1 of the confirmed cases, public health workers must
find approximately 14 persons who have been exposed. Data show that, of
the more than 100,000 persons per year being exposed to TB in the United
States, at least one-quarter have been infected with the TB bacterium.
More than half of TB cases currently occur in foreign-born persons residing in
the United States. Case detection and management present challenges in
this population due to financial, linguistic, and cultural barriers.
-
The recently emerged extensively drug-resistant TB (XDR
TB) is caused by strains of bacteria resistant to the most effective first- and
second-line drugs. Reports indicate that less than 30 percent of
non-HIV-infected patients with XDR TB can be cured, and more than half die
within 5 years of diagnosis.
-
A preliminary estimate by CDC suggests that a
moderately severe influenza pandemic could cause between 89,000 and 207,000
deaths and cost $71 to $166 billion in the United States. Overall, less
than half of persons who are at highest risk for influenza-related
complications seek annual vaccination.
-
When the target for Lyme disease incidence (Obj. 14-8)
was set in 2000, it was based on the availability of a vaccine against the
disease. In February 2002, the only vaccine licensed by the Food and Drug
Administration was removed from the market by the manufacturer, who cited poor
sales. The absence of a commercially available vaccine is a significant
obstacle to meeting the target of the objective.
-
Approximately 1.7 million healthcare-associated
infections (HAIs) occur in the United States each year and are associated with
99,000 deaths annually. HAIs include surgical site infections,
ventilator-associated pneumonia, catheter-associated urinary tract infections,
and infections such as methicillin-resistant Staphylococcus aureus and
Clostridium difficile.
-
Through the Vaccines for Children Program (VFC), which
has more than 45,000 sites, CDC is seeking to better define and enhance the
infrastructure needed to deliver new vaccines to VFC-eligible adolescents and
is establishing adolescent program coordinators in each state.
-
Because of the implementation of hepatitis A
vaccination recommendations and other interventions, as of 2005, new cases of
hepatitis A had decreased by approximately 88 percent nationwide since 1995 and
had fallen to a rate of only 1.5 cases per 100,000, the lowest rate ever
recorded. Also by 2005, the incidence of acute hepatitis C virus
infection had declined approximately 80 percent since the late 1980s.
-
Efforts to reduce the number of courses of antibiotics
prescribed for ear infections in children are supported by the CDC-developed
Get Smart campaign, a national program that promotes appropriate
antibiotic use in the community. CDC partners with states and plans to
expand its partnerships to include pharmacists and employers.
-
Evidence shows that, through the herd
effect, giving pneumococcal vaccine (PCV-7) to children has contributed
to a decline in new cases of invasive pneumococcal disease in adults.
From 1998 to 2003, for every case prevented through direct vaccination, at
least two additional cases were prevented among those who were not themselves
immunized. Evaluation and assessment infrastructures were essential to
understanding the impact of the PCV-7 vaccine and will be important as new
vaccines are introduced, not only to measure their impact but also to detect
emerging strains of disease that may not be prevented by the vaccine.
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In 2005, to provide a successor to an earlier system,
CDC created the National Healthcare Safety Network, a secure, Web-based
surveillance system used by 500 to 700 healthcare facilities throughout the
United States to collect and analyze data on healthcare-associated infections
(about 1.7 million cases and some 99,000 deaths annually), as well as
antimicrobial use and resistance patterns in their facilities. These data
are analyzed and reported by CDC and are available to other organizations, such
as state agencies, with public reporting mandates. This reporting tool
can be used by any healthcare facility in the country and is a critical element
in CDCs patient safety agenda.
Approaches for Consideration
Participants in the Progress Review made the following
suggestions for public health professionals and policymakers to consider as
steps to enable further progress toward achievement of the objectives for
Immunization and Infectious Diseases:
-
Initiate preteen vaccination campaigns designed to
reach parents of 11- to 12-year-olds and their healthcare providers to raise
awareness of new vaccines available to enhance health in this age group.
Encourage development of an adolescent equivalent of the well-defined regularly
scheduled pediatric well-child visits for young children.
-
Expand influenza vaccine recommendations to include
additional groups at increased risk of complications from the disease.
-
Promote universal vaccination of adults in high
prevalence settings, such as STD clinics and HIV counseling and testing
sites. To expand capacity in such settings, encourage states to use
section 317 immunization funds to purchase hepatitis B vaccine. Foster
the creation of a national system to track delivery of hepatitis B vaccinations
in these settings.
-
Strengthen the surveillance system associated with Lyme
disease.
-
In light of the fact that diagnosis of TB disease
currently relies on the tuberculin skin test, which has been in use for 125
years, accelerate efforts to evaluate promising new diagnostic tests for TB in
programmatic settings, as well as rapid tests for the detection of TB drug
resistance.
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To heighten the state of preparedness to deal with any
influenza pandemic, strengthen the national, state, and local infrastructure
for responding to seasonal influenza outbreaks.
Contacts for information about Healthy
People 2010 focus area 14Immunization and Infectious
Diseases:
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[Signed November 13, 2007] Anand K. Parekh, M.D.
Acting Deputy Assistant Secretary for Health (Science and
Medicine)
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