Progress Toward Healthy People 2010 Targets

The following discussion highlights objectives that met or exceeded their 2010 targets; moved toward the targets, demonstrated no change, or moved away from the targets; and those that lacked data to assess progress. Progress is illustrated in the Progress Quotient bar chart (see Figure 14-1), which displays the percent of targeted change achieved for objectives and subobjectives with sufficient data to assess progress.

Objectives that met or exceeded their targets. Twenty-three of the 67 objectives and subobjectives with tracking data met or exceeded their targets. These objectives represent each of the five subsections within this focus area: diseases preventable through universal vaccination, diseases preventable through targeted vaccination, infectious diseases and emerging antimicrobial resistance, vaccination coverage and strategies, and vaccine safety.

Six objectives and subobjectives relating to diseases preventable through vaccination achieved or exceeded their targets. The targets for reducing cases of diphtheria in persons under 35 years of age (14-1b), polio in persons of all ages (14-1h), and hepatitis B in occupationally exposed workers (14-3g) were met. Also, bacterial meningitis among children aged 1 to 23 months (14-4) exceeded its target of 8.6 cases, declining from a baseline of 13.0 new cases per 100,000 children aged 1 to 23 months in 1998 to 8.0 new cases in 2002. The targets for reducing new cases of invasive pneumococcal infections and penicillin-resistant pneumococcal infections in children under 5 years of age (14-5a and c) were exceeded.

The target for reducing new cases of hepatitis A (14-6) was surpassed. Between 1997 and 2003, the rate fell from 11.2 new cases per 100,000 population to 2.6 cases per 100,000 population—below the target of 4.3 cases. This decline reflects the impact of routine vaccination of children in States that historically had elevated rates of hepatitis A.⁴ In October 2005, ACIP voted to expand the recommendations for hepatitis A vaccination to include routine vaccination of all children 12 to 23 months of age. The rate for meningococcal disease among all age groups (14-7) exceeded its target.

Four objectives and subobjectives concerning infectious diseases and emerging antimicrobial resistance met or exceeded their targets. Invasive early onset group B streptococcal (GBS) disease (14-16) decreased, exceeding its target in 2002. The use of intrapartum antibiotic prophylaxis among women colonized late in pregnancy with GBS has contributed to the progress.⁵ To further facilitate progress, the Centers for Disease Control and Prevention (CDC) is monitoring and improving the implementation of universal prenatal GBS screening recommendations.⁶ States are performing various supportive activities to decrease GBS disease. Some States have made perinatal GBS disease a reportable condition, and 11 States have adopted GBS-related questions available through the Pregnancy Risk Assessment and Management Survey, which will allow them to monitor prevention implementation. With the evaluation of labor and delivery records from 2003 and 2004, partner States that participate in the Emerging Infections Program will be able to identify missed opportunities for prevention and problems with implementation.⁷

ICU-acquired infections (14-20) also met the target. Catheter-associated urinary tract infection (14-20a), central-line associated bloodstream infection (14-20b), and central-line associated bloodstream infection in neonatal ICU infants weighing less than 1,000 grams (14-20d) exceeded their targets. Subobjective 14-20d achieved 133 percent of its targeted change. This reduction may be the result of efforts to focus on compliance with prevention practices and guidelines that have been proven effective.⁸

Nine subobjectives within vaccination coverage and strategies met or exceeded their targets. Vaccine coverage rates for children aged 19 to 35 months for Haemophilus influenzae type B (14-22b), hepatitis B (14-22c), measles-mumps-rubella (MMR) (14-22d), and polio (14-22e) met or exceeded their targets. The subobjectives with sufficient data to measure immunization progress for diphtheria-tetanus-acellular pertussis (DTaP) (14-23a), MMR (14-23b), and polio vaccine (14-23c) coverage rates of children in day care (14-23) achieved their targets. These results may be due to education and programmatic efforts made by health care providers, public- and private-sector partners, State and local government agencies, and Federal agencies such as CDC. Among children in day care, 95 percent were covered by DTaP (14-23a), and 96 percent were covered by the polio vaccine (14-23c). Immunization coverage rates in adolescents aged 13 to 15 years for MMR vaccine (14-27b) and tetanus-diphtheria booster (14-27c) both met their targets.

Finally, two subobjectives monitoring vaccine safety met or exceeded their targets. Vaccine-associated paralytic polio (14-30a) dropped from five cases in 1997 to zero in 2000. Between 1998 and 2001, febrile seizures following pertussis vaccination (14-30b) dropped from 152 cases to 53 cases, below the target of 75 cases. However, febrile seizures following pertussis vaccination (14-30b) has seen considerable upward and downward fluctuation over the past 5 years. This latest measurement representing a decline may not be representative of the overall trend.

Objectives that moved toward their targets. Similar to the range of measures that met or exceeded their targets, the 39 objectives and subobjectives that moved toward their targets span most of the sections of this focus area.

Fourteen objectives and subobjectives from the section related to diseases preventable through universal vaccination made progress in the first half of the decade. Many were subobjectives related to cases of vaccine-preventable diseases: congenital rubella syndrome (14-1a), hepatitis B in persons aged 2 to 18 years (14-1d), measles (14-1e), mumps (14-1f), rubella (14-1i), tetanus (14-1j), and varicella (14-1k). Although the elimination of measles (14-1e) did not meet its target of zero cases, the disease has not been considered endemic in the United States since 2000.⁹ Cases of rubella (14-1i) declined to seven cases in 2003, approaching its target of zero cases. Absence of transmission of rubella virus is supported by a pattern of virus genotypes consistent with rubella virus originating in other parts of the world.

Cases of chronic hepatitis B virus infections in infants and children aged 2 years and under (14-2) declined, achieving 63 percent of the targeted change. Cases of acute hepatitis B also decreased for other populations: 19- to 24-year-olds (14-3a) achieved 58 percent of the targeted change, 25- to 39-year-olds (14-3b) achieved 41 percent, and persons aged 40 years and older (14-3c) achieved 67 percent. Within specific risk groups, the number of hepatitis B cases among injection drug users (14-3d) declined, and this objective achieved 75 percent of the targeted change; the number of cases among heterosexually active persons (14-3e) achieved 61 percent. While the number of cases among occupationally exposed workers (14-3g) declined and the subobjective met its target, the number of cases among men who have sex with men (14-3f) increased, and this subobjective moved away from its target.

Numerous activities are in place to support hepatitis B-related objectives. Efforts are also focused on implementing national perinatal hepatitis B prevention programs and the routine hepatitis B vaccination of children. Recommendations have also been developed to increase hepatitis B vaccination of adults at risk of infection and are an important component of the national strategy to eliminate hepatitis B virus infection.¹⁰

Invasive pneumococcal infections in older adults (14-5b) improved and came close to meeting its target of 42 cases per 100,000 persons aged 65 years or older, achieving 95 percent of the targeted change.

Six objectives related to infectious diseases and emerging antimicrobial resistance progressed toward their targets, including objectives regarding hepatitis C (14-9), tuberculosis (TB) (14-11) and curative therapy for TB (14-12), peptic ulcer hospitalizations (14-17), and antibiotics prescribed for ear infections (14-18) and the common cold (14-19).

Cases of acute hepatitis C (14-9) achieved 60 percent of its targeted change by 2003, approaching its target of 1 new case per 100,000 population. Through CDC, HHS continues to implement the National Hepatitis C Prevention Strategy.¹¹ Furthermore, more than half of all States have developed or are preparing comprehensive viral hepatitis prevention plans. The use of existing public health programs and facilities—such as sexually transmitted disease and AIDS treatment facilities, HIV/AIDS counseling and testing sites, and drug treatment programs—will help reach more persons at risk.

Progress was made for total cases of TB (14-11) and curative therapy for the disease (14-12). After substantial progress between 1998 and 2002, the rate of decline in new cases of TB between 2002 and 2003 was small, raising concerns that progress toward TB elimination may be slowing.¹² In 2003, the rate for TB was 5.1 new cases per 100,000 population. Reaching the target of 1 new TB case per 100,000 population will require an acceleration of TB control efforts and better methods to reach underserved racial and ethnic populations. Increasingly, TB is being seen in foreign-born persons now residing in the United States. Case detection and management present challenges in this population due to financial, linguistic, and cultural barriers. Most TB control activities occur at State and local levels, and partners include TB programs in all U.S. States and Territories. Through CDC, HHS supports 50 State and 10 city health departments to implement evidence-based TB control measures. These measures are focused on detecting and treating persons with the disease, identifying and treating persons known to be exposed to persons with TB, and screening high-risk populations.¹³

Several other infectious diseases showed a decline in the rates of new cases. Timely identification and treatment of Helicobacter pylori stomach and duodenal infections improved. Consequently, the new cases of infection dropped, mostly among children. As a result, hospitalizations secondary to severe peptic ulcer disease (14-17) dropped from 71 hospitalizations per 100,000 population to 63 hospitalizations per 100,000 population.¹⁴

Reducing the number of courses of antibiotics prescribed for ear infections in children (14-18) moved toward its target. Efforts to reach this target are supported by the "Get Smart"¹⁵ campaign. This effort addresses antibiotic use and guidelines issued by provider organizations regarding the treatment of children with ear infections when the treatment involves observation without a prescription of an antibiotic. The number of antibiotics prescribed for the common cold (14-19) also decreased, and the objective moved toward its target.

Eighteen objectives and subobjectives dealing with vaccination coverage and strategies made progress toward their targets. These included universally recommended vaccinations (14-22), fully immunized young children (14-24a), childhood vaccination coverage tracked by health care providers (14-25), children participating in population-based immunization registries (14-26), vaccination coverage among adolescents (14-27), hepatitis B vaccination among high-risk groups (14-28), and influenza and pneumococcal vaccination of high-risk adults (14-29).

Vaccination rates of all age groups demonstrated progress. Among children 19 to 35 months of age, achieving and maintaining effective vaccination coverage levels for universally recommended vaccines—including DTaP (14-22a), varicella (14-22f), and pneumococcal conjugate vaccine (PCV) (14-22g)—moved toward their targets. Because of these and other gains, the proportion of fully immunized young children (14-24a) achieved 29 percent of the targeted change.

Just as the objectives related to the vaccinations themselves are important, so are the objectives related to evidence-based strategies for raising vaccination coverage rates. The proportion of public and private health care providers who have measured childhood vaccination coverage levels (14-25) and the proportion of children participating in population-based immunization registries (14-26) moved toward their targets.

Subobjectives related to routine vaccination coverage levels for adolescents (14-27) also moved toward their targets. Hepatitis B vaccination in adolescents aged 13 to 15 years achieved 79 percent of its targeted change (14-27a), and varicella vaccine coverage (14-27d) for the same age group achieved 71 percent of its targeted change.

Children are not the only at-risk population among which vaccinations increased. Hepatitis B vaccination coverage in long-term hemodialysis patients (14-28a) achieved 46 percent of the targeted change, men who have sex with men (14-28b) achieved 8 percent, and occupationally exposed workers (14-28c) achieved 31 percent.

Influenza and pneumococcal vaccination of high-risk adults (14-29) also demonstrated progress. The subobjectives within this objective cover individuals 65 years and older and institutionalized persons aged 18 years and older. The increase in adult vaccination rates may have been influenced by the ACIP adult recommendation schedule, by the doubling of reimbursement for the administration of the influenza vaccine for Medicare recipients in 2002 by the Centers for Medicare & Medicaid Services (CMS), CMS's enabling the implementation of standing orders in long-term care facilities in 2003, the establishment of the National Influenza Vaccine Summit in 2001, and the inclusion of pneumococcal vaccine in national guidelines for care of persons with diabetes. Evidence suggests that giving pneumococcal vaccine to children has contributed to a decline in new cases of invasive pneumococcal disease in adults.¹⁶

A subobjective dealing with vaccine safety also progressed toward its target. Increasing the number of persons under active surveillance for vaccine safety via linked databases (14-31a) moved toward its target. In 2000, 8 million persons were being monitored, 5 million less than the target of 13 million. Concerns of health care management organizations about patient confidentiality may present a challenge to achieving this target.

Objectives that moved away from their targets. Five objectives and subobjectives moved away from their targets: cases of Hib (14-1c), cases of pertussis (14-1g), hepatitis B in men who have sex with men (14-3f), invasive penicillin-resistant pneumococcal infections in persons aged 65 years and older (14-5d), and Lyme disease (14-8).

Increasing numbers of invasive Haemophilus influenzae (Hi) infections caused by either Hib or Hi of unknown type were noted in children under age 5 years (14-1c). The number of cases of invasive Hi (14-1c) increased from 163 cases in 1998 to the most recent total of 259 cases in 2003.¹⁷ One aspect of this increase can be attributed to a decrease in the proportion of reported invasive Hi infections in children under age 5 years who were typed from 55 percent in 1998 to 41 percent in 2003.¹⁷ Furthermore, serotyping discrepancies—or differences in classification—between State and CDC surveillance laboratories exist.¹⁸ Through CDC, HHS is working to encourage State health departments to collect the Hi isolates that cause invasive disease in children under age 5 years and forward them to CDC for classification confirmation. The number of cases of pertussis in children under 7 years of age (14-1g) increased, and the objective moved away from its target. A real increase in circulation of Bordetella pertussis may have occurred, but how much of this increase may reflect increased transmission and increased recognition, diagnosis, and reporting is difficult to assess. Recently, the first pertussis antigen-containing vaccines for persons over 6 years of age were licensed, and ACIP has recommended their use in adolescents and adults.¹⁹

Cases of hepatitis B among men who have sex with men (MSM) (14-3f) increased from a baseline of 5,209 cases in 1997 to 5,510 cases in 2003, moving away from the 2010 target of 1,302 cases. This change appears to be associated with a resurgence in unsafe sexual practices.²⁰

Pneumococcal infections due to penicillin-resistant bacteria (14-5d) increased from 8 new cases per 100,000 persons aged 65 years and older in 1997 to 10 new cases in 2002, moving away from the target of 7 new cases per 100,000 persons aged 65 years and older. Antibiotic-resistant pneumococci are spreading in part due to the overuse of antibiotics. Through CDC, HHS is working on improving coverage of the new PCV for young children and pneumococcal polysaccharide vaccine for high-risk adults.²¹

Within endemic States, annual cases of Lyme disease (14-8) climbed from a baseline of 17.4 new cases per 100,000 population to 32.5 new cases per 100,000 population. When the goal of 9.7 cases per 100,000 population was set in 2000, it was based on the availability of a Lyme disease vaccine. In February 2002, the only vaccine for Lyme disease licensed by the Food and Drug Administration was removed from the market by the manufacturer.²² The absence of a viable vaccine for Lyme disease poses a significant obstacle to meeting the Healthy People 2010 target.

Objectives that could not be assessed. As of January 2005, no data were available to access progress on identification of persons with chronic hepatitis C (14-10) or universally recommended vaccine among adolescents (14-24b). Data beyond baseline were not available for treatment for latent TB infection (14-13), timely laboratory confirmation of TB cases (14-14), vancomycin use in intensive care units (14-21), ventilator-associated pneumonia in intensive-care-unit patients (14-20c) and infants weighing 1,000 grams or less at birth in intensive care, vaccination coverage for children in licensed day care facilities (14-23d, e, and l) and kindergarten (14-23f through k), hepatitis B coverage among MSM (14-28b), influenza vaccine for health care workers (14-29g), and electronically submitted reports of vaccine-adverse events (14-31b).

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