Immunization Program Managers Meeting 2010 Stewards in a Time of Change Anne Schuchat, MD RADM, US Public Health Service Assistant Surgeon General Director, National Center for Immunization and Respiratory Diseases Association of Immunization Managers Annual Meeting February 1, 2012 Office of Infectious Diseases
The Good Old Days
Routes We ve Travelled so Far Record low VPDs Achieved and sustained high childhood immunization Reduced racial, ethnic, economic disparities Introduced multiple new antigens Most teen vaccines on favorable flight paths
Comparison of 20 th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases Disease 20th Century 2011 Annual Morbidity Reported Cases National Center for Immunization & Respiratory Diseases Historical Comparisons of Vaccine-Preventable Disease Morbidity in the U.S. Percent Decrease Smallpox 29,005 0 100% Diphtheria 21,053 0 100% Measles 530,217 212 > 99% Mumps 162,344 370 > 99% Pertussis 200,752 15,216 92% Polio (paralytic) 16,316 0 100% Rubella 47,745 4 > 99% Congenital Rubella Syndrome 152 0 100% Tetanus 580 9 98% Haemophilus influenzae 20,000 8* > 99% Source: JAMA. 2007;298(18):2155-2163 Source: CDC. MMWR January 6, 2012;60(51);1762-1775. (provisional 2011 data) * Haemophilus influenzae type b (Hib) < 5 years of age. An additional 14 cases of Hib are estimated to have occurred among the 237 reports of Hi (< 5 years of age) with unknown serotype.
Comparison of Pre-Vaccine Era Estimated Annual Morbidity with Current Estimate: Vaccine- Preventable Diseases Disease Pre-Vaccine Era Annual Estimate 2010 Estimate Percent Decrease Hepatitis A 117,333 7,138 94% Hepatitis B (acute) 66,232 9,428 86% Pneumococcus (invasive) all ages 63,067 39,500 # 37% < 5 years of age 16,069 4,400 ## 73% Rotavirus (hospitalizations, < 3 years of age) 62,500 2,500 ### 96% Varicella 4,085,120 281,873 93% JAMA. 2007;298(18):2155-2163 CDC. MMWR. February 6, 2009 / 58(RR02);1-25 # CDC. Active Bacterial Core surveillance Provisional Report; S. pneumoniae 2010. http://www.cdc.gov/abcs/reports-findings/survreports/spneu09.html ## 2010 (provisional) Active Bacterial Core surveillance ### New Vaccine Surveillance Network (unpublished)
Percent vaccinated 100 90 80 70 60 50 40 30 20 10 0 Estimated Vaccination Coverage, Children 19-35 Months,1991-2010* Hib (3+) HP 2020 Target MMR (1+) DTP/DTaP (3+) Hep B (3+) Varicella (1+) PCV (4+) Varicella (2+) 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 R V Hib * Source: NHIS (1991-1993); NIS (1994-2010) children 19-35 months and NIS-Teen (2006-2010) teens 13-15 years Target is 80 percent for Rotavirus, Tdap (1+), MCV4 (1+), HPV (3+) and 90% for varicella (2+) Full series Hib ( 3 or 4 doses, depending on product type received). Brand of Hib vaccine received was not collected on the NIS prior to 2009.
Increasing Pediatric Influenza Vaccine Coverage, National Immunization Survey (Final 2010-11 vs. 09/10) http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm
Pediatric Flu Vaccine Coverage by Race/Ethnicity: Preliminary results - Nov 2011 vs. Nov 2010 Children (6m-17 years) November 2010 % ± 95% CI November 2011 % ± 95% CI Hispanic 27.8 ± 10.1 43.4 ± 5.8 Non-Hispanic, white only 31.9 ± 6.4 33.5 ± 3.3 Non-Hispanic, black only 26.8 ± 17.3 35.5 ± 8.1 Non-Hispanic, other 35.0 ± 17.1 43.6± 7.7 Estimate from Nov 2011 NFS stat sign different from Nov 2010 NFS estimate, p<0.05 Estimate may not be reliable, confidence interval half-width >10.0 or (CI half width/estimate) < 0.6 Includes Asian, Am Indian and Alaska Native (AIAN), Native Hawaiian or other Pacific Islander, multiracial, and other races. Estimate stat sign different from estimate for non-hispanic whites during the same time period, p<0.05 Data Source: National Flu Survey www.cdc.gov/flu/professionals/vaccination/national-flu-survey.htm
Percentage of Children Vaccinated PCV7 Coverage in Children 19-35 Months, by Race United States, 1998-2009 PCV7 introduced 100 90 80 70 60 50 40 30 20 10 0 Black White National Immunization Survey Year
Cases per 100,000 population 180 160 Rates of IPD in Children <5 years Caused by PCV7 Serotypes, by Race ABCs, 1998-2009 PCV7 introduced Year Rate Ratio Rate Difference 140 120 1998 2.6 94 100 80 60 40 Black White 20 0 Year
Rate (cases/100,000 children) 2010 2010 2010 2011 2011 Rates of PCV13-serotype IPD in children <2 years, 2006-2008 vs. 2010 and 2011, by quarter 30 Baseline 2010/2011 25 20 15 10 5 0 Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Source: Active Bacterial Core surveillance (ABCs), unpublished P<0.002
Hospitalization Incidence All-cause acute gastroenteritis (AGE) and rotavirus-positive hospitalizations among children <3 years, NVSN, 2006-2011 250 200 150 211 194 147 168 Est. 86-88% vaccine coverage * 100 107 101 101 104 50 0 44 27 9 4 2006 2007 2008 2009 2010 2011 All-cause AGE Rotavirus 0% vaccine coverage * Payne DC, unpublished 2012 * >1 dose, any type DEPARTMENT OF HEALTH AND HUMAN SERVICES
Percent vaccinated Estimated Vaccination Coverage, Children 19-35 Mos and 13 15 yrs, 1991-2010* 100 90 80 70 60 50 40 30 20 10 0 Hib (3+) HP 2020 Target MMR (1+) DTP/DTaP (3+) Hep B (3+) Varicella (1+) PCV (4+) Tdap (1+) Varicella (2+) 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 Hib MCV (1+) R V * Source: NHIS (1991-1993); NIS (1994-2010) children 19-35 months and NIS-Teen (2006-2010) teens 13-15 years Target is 80 percent for Rotavirus, Tdap (1+), MCV4 (1+), HPV (3+) and 90% for varicella (2+) Full series Hib ( 3 or 4 doses, depending on product type received). Brand of Hib vaccine received was not collected on the NIS prior to 2009.
Percent vaccinated Estimated Vaccination Coverage, Children 19-35 Mos and 13 15 yrs, 1991-2010* 100 90 80 70 60 50 40 30 20 10 0 DTP/DTaP (3+) Hib (3+) Hep B (3+) Varicella (1+) PCV (4+) Tdap Hib MCV (1+) (1+) R V HPV 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 * Source: NHIS (1991-1993); NIS (1994-2010) children 19-35 months and NIS-Teen (2006-2010) teens 13-15 years Target is 80 percent for Rotavirus, Tdap (1+), MCV4 (1+), HPV (3+) and 90% for varicella (2+) Full series Hib ( 3 or 4 doses, depending on product type received). Brand of Hib vaccine received was not collected on the NIS prior to 2009. Among females HP 2020 Target MMR (1+) Varicella (2+) HPV (3+)
Need a better cruising altitude for HPV!
Storm Clouds Ahead Budgetary challenges Deficit reduction, belt tightening Transition to Affordable Care Act Underinsurance Social trends Exemptors Vaccine hesitancy
Clinicians Frequent Flier Benefits Just Got a Whole Lot Better Provider Resources for Vaccine Conversations with Parents www.cdc.gov/vaccines/conversations Give Feedback on Provider Resources www.cdc.gov/vaccines/tellus Health Care Professional Home Page www.cdc.gov/vaccines/hcp Get the Picture Childhood Video www.youtube.com/user/cdcstreaminghealth
Measles, United States, 2011 Geographic Distribution of Cases (n=222) = 1 case 19
Measles Outbreaks*, United States, 2011 112/222 (50%) annual cases were outbreak-associated 17 total outbreaks Median outbreak size was 6 (range: 3 21) 44% of outbreak-associated cases were unvaccinated philosophical belief exemptors *Outbreak = 3 or more epidemiologically linked cases 20
Number of Cases Measles, United States, 2001-2011 Importations by WHO Region 80 70 60 Unknown South East Asian Eastern Mediterranean American Western Pacific European African 50 40 30 20 10 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Year 21
Measles is Epidemic in France
Opportunities to Strengthen Public Health Role in Immunization in Context of ACA Strengthen evidence base for vaccine policy & programs Monitor impact of ACA on access to quality IZ services Respond to outbreaks of VPDs Prevention of disease Enhance partnership w/ community vaccinators and private providers Improve preparedness to deliver vaccines in public health emergencies Improve access to uninsured poor adults
Childhood Immunization Series Provides Big Savings For each birth cohort vaccinated against 13 diseases in accordance with the 0-6 yo childhood schedule for DTaP, Hib, IPV, MMR, Hepatitis B, Varicella, Hepatitis A, Pneumo-7, and Rotavirus vaccines: 42,000 lives are saved 20M cases of disease are prevented 13.6 billion dollars in direct costs are saved 68.9 billion dollars in direct plus indirect (societal) costs are saved For each dollar invested in these vaccinations, $10.20 is saved Data presented at: National Immunization Conference, March 2011 Prelim results of update from Zhou et al, Arch of Ped & Adol Med 2005
Pressures on 317 Program Economic realities of Fed budget environment Expectation ACA insurance reform over next few yrs will expand coverage for IZ services to include majority of Americans Expectation that over time Providing 317 vaccine to fully insured people won t be acceptable Size of 317 population will decrease ACA requirement for IZ services to be covered will raise bar for strength of the evidence base Impact, effectiveness, safety
Turbulence Life jackets are under the seat in front of you!
Emergency Equipment for Program Managers Billing Deputization IT modernization
Public Sector Vaccination and Fully Insured Patients Starting with FY13, do not develop spend plans or vaccine financing policies that program Section 317 vaccine for fully insured individuals. Providers should be instructed to routinely screen out fully insured individuals from program eligibility unless state funding is used to pay for the vaccine. To avoid missed opportunities to vaccinate at public health clinics, we encourage vaccinating with private purchase vaccine, supported by billing private insurance for the vaccine and admin fee. Special session on Billing TODAY!! 4:30 7:30 pm, Aud. B: For Participants, stakeholders and interested parties.
Modernizing the Immunization Program with IT Investments * Barcodes Doctor s offices E-health records * Interoperability Health Departments and Immunization Information System * VTrckS
Checklist for a Smooth Landing 2013 Funding Opportunity Announcement Emphasis on priority activities Commitment to share best practices E.g., HPV webinars, Billing toolkit Attending 2012 Program Managers meeting!