National Center for Immunization & Respiratory Diseases
Immunization Update:National Perspective
Melinda Wharton, MD, MPH
Director, Immunization Services Division
Texas Immunization Conference
Dallas, TexasOctober 25, 2019
Disclosures
▪ I work for the Centers for Disease Control and Prevention
▪ I have no financial interests to disclose
▪ I will not be discussing investigational products or off-label uses of vaccines
Learning Objectives
▪ Describe current trends in vaccine coverage in the United States
▪ Identify at least one strategy to improve vaccine coverage that you can implement in your practice or work setting.
Vaccines remain one of the most effective ways for protecting babies, children, and adults from
disease, disability, and death.
Comparison of 20th Century Annual Morbidity and Current Morbidity:
Vaccine-Preventable Diseases
Disease
20th Century
Annual Morbidity†
2018
Reported Cases † †
Percent
Decrease
Smallpox 29,005 0 100%
Diphtheria 21,053 1 > 99%
Measles 530,217 273 > 99%
Mumps 162,344 2,251 99%
Pertussis 200,752 13,439 93%
Polio (paralytic) 16,316 0 100%
Rubella 47,745 5 > 99%
Congenital Rubella Syndrome 152 0 100%
Tetanus 580 20 97%
Haemophilus influenzae 20,000 27* > 99%
† JAMA. 2007;298(18):2155-2163† † CDC. MMWR January 6, 2017/ 65(52);ND-924 – ND-941. (MMWR 2016 week 52 provisional data)
* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 11 cases of Hib are estimated to
have occurred among the 221 reports of Hi (< 5 years of age) with unknown serotype.
Childhood Immunization Provides Big SavingsVaccines for Children: 25 years of protecting America’s children
CDC estimates that vaccination of children born between 1994 and 2018:
▪ Prevent 419 million illnesses
▪ Prevent 26.8 million hospitalizations
▪ Help avoid 936,000 early deaths
▪ Save nearly $406 billion in direct costs and $1.88 trillion in total society costs
▪ Every dollar spent in childhood vaccination ultimately saves $10.10.
Updated data from previous article: Benefits from Immunization During the Vaccines for Children Program Era – United States, 1994-2013. MMWR. 25 April 2014
Nationally, vaccination of young childrencontinues to be the norm.
Vaccine-specific coverage among children 19-35 months, National Immunization Survey-Child, 1994-2017
0
10
20
30
40
50
60
70
80
90
100
Pe
rce
nt
Vac
cin
ate
dHib-FS
Vaccination Coverage Among Children Aged 19-35 Months -- United States, 2017Additional information on vaccination coverage estimates and interpreting trendsAbbreviations: MMR = measles, mumps, and rubella vaccine; DTP/DTaP = diphtheria and tetanus toxoids and pertussis vaccine / diphtheria and tetanus toxoids and acellular pertussis vaccine; Hib = Haemophilus influenzae type b vaccine; FS = full series; HepB = hepatitis B vaccine; PCV = pneumococcal conjugate vaccine; HepA = hepatitis A vaccine
3+ HepB
1+ Varicella
4+ PCV
3+ Hib Rotavirus
2+ HepA
1+ MMR
4+ DTP/DTaP
3+ DTP/DTaP
3+ Polio
SUPPLEMENTARY FIGURE 1. Estimated Vaccination Coverage by Age 24 Months, by Birth Year, National Immunization Survey-Child 2012-2018, United
States
~
3+ Polio
3+ HepB
1+ Var
1+ MMR
4+ DTaP4+ PCV
Hib-FSHepB birth dose 2+ HepA
Rotavirus
4:3:1:3*:3:1:4
2+ Influenza
Source: CDC National Immunization Surveys; by birth cohort 2012-2018
Very Few U.S. Toddlers Have Received No Vaccines
0
0.2
0.4
0.6
0.8
1
1.2
1.4
2011 2012 2013 2014 2015 2016
We’ve got our challenges.
Coverage with some vaccines in some populations should be higher than it is.
0.0
20.0
40.0
60.0
80.0
100.0
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Pe
rce
nt
Vac
cin
ate
d (
%)
Year
≥1 Tdap
≥1 MenACWY
≥2 MenACWY
≥1 HPV
≥3 HPV
HPV UTD
Revised Definition ofAdequate Provider Data† Single Sample Frame Estimates§
ACIP recommendation2011–2015¶
ACIP recommendation2016–2018¶
Trends in Vaccination Coverage among Adolescents Aged 13-17 Years, NIS-Teen, United States, 2006-2018
≥ 70%
60% - 69%
50% - 59%
40% - 49%
30% - 39%HI
AK
DC
Range:78.1% (RI)
to32.6% (MS)
Estimated Up-to-Date HPV Vaccination Coverage among Adolescents, 2018
National Coverage = 51%
Estimated Vaccine Coverage among Adults aged ≥19 Years by Age Group and Risk Status, NHIS, 2010-2017
0
10
20
30
40
50
60
70
80
90
100
2010 2011 2012 2013 2014 2015 2016 2017
Per
cen
tage
Year
Influenza - age ≥19 yrs Pneumococcal - age 19-64 yrs, increased riskPneumococcal - age ≥65 yrs Tetanus-toxoid (Td or Tdap) - age ≥19 yrsHerpes zoster - age ≥60 yrs Influenza - age ≥19 yrs, high riskTdap - age ≥19 yrs
National Health Interview Survey
Disparities in vaccine coverage persist
Vaccination Coverage Estimates among Adolescents Aged 13-17 Years by MSA status, NIS-Teen, United States, 2018
*
*
MSA = Metropolitan statistical area
* Statistically different from adolescents living in MSA principal cities (p<0.05).
88.6 86.5
71.9
56.1
89.7 88.3
66.6
49.1
86.879.5
59.5
40.7
0.0
20.0
40.0
60.0
80.0
100.0
≥1 Tdap ≥1 MenACWY ≥1 HPV HPV UTD
Pe
rce
nt
Vac
cin
ate
d
Vaccine
MSA Principal City MSA Non-Principal City non-MSA
**
**
*
Estimated Influenza Vaccine Coverage among Adults aged ≥19 Years by Race/Ethnicity, NHIS, 2016-2017 Season
0 10 20 30 40 50 60
White
Black
Hispanic
Asian
Other
National Health Interview Survey
Measles is still a threat.
7
0
0
77
0
0
00
0
00
0
00
0
Measles Cases Reported by Month, 2019 (as of October 3)
https://www.cdc.gov/measles/cases-outbreaks.html
Measles has Increased 300% Globally in 2019Measles incidence for 12-month period
Top 10**
Country Cases Rate
Madagascar 92181 3702.86
Ukraine 85833 1931.5
India**** 41264 31.16
Philippines 32821 317.66
Nigeria 25044 134.65
Pakistan 11247 58.21
Yemen 10562 382.9
Brazil 9983 48.08
DR Congo 8971 113.94
Kazakhstan 8476 471.21
Other countries with high
incidence rates***
Country Cases Rate
Georgia 5024 1279.87
The Republic of
North
Macedonia
1369 657.79
Kyrgyzstan 2982 500.69
Israel 4011 489.63
Bosnia and
Herzegovina1150 327
• Notes: Based on data received 2019-07 and covering the period between 2018-06 and 2019-05 - Incidence: Number of cases / population* * 100,000 - * World population prospects, 2019 revision - ** Countries with the highest number of cases for the period - *** Countries with the highest incidence rates (excluding those already listed in the table above) ****WHO classifies all suspected measles cases reported from India as measles clinically compatible if a specimen was not collected as per the algorithm for classification of suspected measles in the WHO VPD Surveillance Standards. Thus numbers might be different between what WHO reports and what India reports.
Measles cases from countries with known discrepancies between case-based and aggregate surveillance, as reported by country
Country YearCases in Case-
basedCases in Aggregate Data Source for aggregate #s
DR Congo 2018 5597 67072 SITUATION EPIDEMIOLOGIQUE DE LA ROUGEOLE EN RDC, Week of 09/07/20192019 6138 118,647
Somalia 2018 131 9135Somali EPI/POL Weekly Update Week 26
2019 28 1967
Measles is still a threat,especially in communities with low vaccine
coverage.
Responding to dynamics shared by recent outbreaks
Pockets of low vaccination
Myths & misinformation
Vaccine access
Pockets of low vaccination
Close-knit, under-vaccinated communities a key vulnerability
Each community is unique, with distinct factors affecting vaccination
Isolation or insularity
Localized misinformation
Access issues
Distrust of public authorities
Myths and misinformation
Myths have always been part of the vaccine landscape
But rapid dissemination and sophistication of misinformation present new challenges
While its impact nationally is unclear, misinformation plays a clear role in under-vaccination in some local communities
Vaccine misinformation can be tailored for specific communities.
Vaccinate with Confidence i D ’ gic framework for strengthening vaccine
confidence and preventing outbreaks of vaccine preventable diseases in the United
States
Protect communitiesUse every tool available to find and protect communities at risk using tailored,
targeted approaches
Empower familiesEnsure parents are confident in decision to vaccinate by strengthening
provider-parent vaccine conversations
Stop mythsUse local partners and trusted messengers, establish new partnerships to
contain the spread of misinformation, and educate critical stakeholders about
vaccines 30
To protect communities from outbreaks, we have to find the communities that are most vulnerable first
New Investments and Activities
L v g D ’ 0 I iz i and Vaccines for Children cooperative agreement to support awardee efforts to find and respond to pockets of low vaccine coverage in their jurisdictions
Use immunization information system data and small-area analyses to pinpoint areas of low vaccination coverage and identify barriers to vaccination
Build immunization program capacity to effectively respond to outbreaks
Vaccinate with Confidence tagline
To ensure parents are confident in the decision to vaccinate, we need to equip health care professionals with resources to have effective vaccine conversations
Vaccinate with Confidence tagline
New Investments and Activities
• Support partners to help vaccine conversations start earlier with parents of very young infants and pregnant women
• Reduce hesitancy and improve v cci cc i ’ community health centers
• Develop provider toolkit to address p ’ v cci q i d i g outbreaks of vaccine-preventable diseases
We must ensure reliable information is not drowned out by misinformation, educate key stakeholders about vaccines, and engage trusted local messengers to provide accurate and reliable information about vaccines
New Investments and Activities
Work with social media companies to promote trustworthy vaccine information
Educate state policy makers on vaccine safety and effectiveness
Engage state and local health officials to advance effective local responses and community-based initiatives to misinformation and hesitancy
In the U.S., 32,100 cancers a year are caused by the types of HPV in our current 9-valent vaccine.
Estimated Number of Cancer Cases Attributable to HPV by Sex, Cancer Type, and HPV Type, United States, 2012-2016
www.cdc.gov/cancer/uscs/pdf/USCS-DataBrief-No10-August2019-h.pdf
HPV-Associated Cancer Rates by State, United States, 2012-2016
Rates per 100,000 populationhttps://www.cdc.gov/cancer/hpv/statistics/state/
13.4-16.0
12.0-13.3
11.4-11.7
8.5-11.3
HPV vaccine is safe and effective.
Initial Post-Licensure Monitoring of 9vHPV
▪ From December 2014 through December 2017, enhanced safety monitoring in VAERS found no unexpected or new safety concerns
– Approximately 29 million doses distributed in the United States during this time
• 7,244 total reports received in VAERS
• 186 (3%) serious reports
• Dizziness, syncope, headache were most frequently reported
– Safety profile consistent with data from 9vHPV pre-licensure clinical trials and similar to post-licensure safety data from 4vHPV monitoring in VAERS
▪ Between October 4, 2015-October 3, 2017, the Vaccine Safety Datalink conducted weekly sequential monitoring among persons aged 9-26 who received 9vHPV
– Approximately 900,000 doses administered and no concerning safety signals detected among pre-specified outcome monitored, which included:
• GBS, appendicitis, injection site reaction, anaphylaxis, stroke, syncope, venous thromboembolism, allergic reaction, chronic inflammatory demyelinating polyneuropathy, pancreatitis, seizures
Based on February 2018 ACIP presentation, https://www.cdc.gov/vaccines/acip/meetings/slides-2018-02.html
11.5%
18.5%
11.8%
9.5%
1.8%
5.3%
8.0%6.5%
0%
5%
10%
15%
20%
14–19 years 20–24 years 25–29 years 30–34 years
Pre
vale
nce
, %
2003–2006
2013–2016
aPR 0.14 (0.08-0.24)
aPR 0.29 (0.15-0.56)
aPR 0.61 (0.36-1.04)
aPR 0.73 (0.41-1.32)
86%*
71%*
Prevalence of Vaccine-type HPV (HPV 6,11,16,18) in Females, 2013-2016 Compared to Pre-vaccine Era
McClung et al. JAH 2019, in press *statistically significant declines
Although HPV vaccine coverage among adolescentshas increased, it’s still not where we need it to be.
Estimated Vaccination Coverage among Adolescents Aged 13-17 Years, National Immunization Survey-Teen, United States, 2006-2018
Walker et al., MMWR 2019. UTD: up-to-date. Revised definition of adequate provider data in 2013.
0
10
20
30
40
50
60
70
80
90
100
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Pe
rce
nt
Va
ccin
ate
d
Survey Year
≥1 MenACWY
≥1 HPV (females)≥1 HPV (males)
≥3 HPV (females)
≥3 HPV (males)
HPV UTD (females)HPV UTD (males)
≥1 Tdap
The provider recommendation for HPV vaccinationreally matters.
Now that Sophia is 11, she is due for vaccinations today to help protect her
from meningitis, HPV cancers, and pertussis.
HPV Vaccination Initiation Coverage by Provider Recommendation, National Immunization Survey-Teen, 2018
Received recommendation?
78%
22%
Yes
No
75%
25%
Vaccinated
Not vaccinated
47%
53%
Vaccinated
Not vaccinated
https://stacks.cdc.gov/view/cdc/80680
Parents who were missing a response, refused to respond, or responded, “don’t know” (n=1,448) were not included in the estimates.https://stacks.cdc.gov/view/cdc/80682
Range:90.7% (MA)
to59.5% (MS)
Percentage of Parents who Reported Receiving a Provider Recommendationfor HPV Vaccine, NIS-Teen 2018
How to Increase Vaccine Coverage
How to Increase Vaccine Coverage (1)
▪ Make a strong provider recommendation
▪ Recommend HPV vaccination the same way Tdap and MenACWY are recommended
▪ Make sure everyone in the office is working together to support your vaccination goals
▪ Assess coverage for every patient on the schedule and prompt clinicians to recommend vaccination
▪ Implement reminder/recall systems
How to Increase Vaccine Coverage (2)
▪ Use standing orders and allow immunization only visits
▪ Make the appointment for the next dose in the series before the patient leaves the office
▪ Assess vaccination coverage at the individual provider level and share feedback to providers
Providers need to be prepared to answerparents’ questions.
Reasons for Not Vaccinating Adolescents with HPV Vaccine, Unvaccinated Adolescents Aged 13-17 Years, NIS-Teen, United States, 2018
Parents of Girls Parents of Boys
Safety concerns/side effects
30% Safety concerns/side effects
22%
Not needed/not necessary
16% Not needed/not necessary
16%
Not sexually active 12% Not recommended 11%
Not recommended 7% Lack of knowledge 8%
Lack of knowledge 4% Not sexually active 7%
Answering parents’ questionshttps://www.cdc.gov/hpv/hcp/answering-questions.html
Frequently asked questions about HPV vaccine safetyhttps://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html
Influenza is a vaccine-preventable disease.
Influenza Vaccine Effectiveness Against Pediatric Deaths, 2010-2014
▪ From July 2010 through June 2014, 358 laboratory-confirmed influenza-associated pediatric deaths were reported among children 6 months-17 years of age
– Vaccination status was determined for 291 deaths
▪ For children overall
– 75 (26%) received vaccine before illness onset
– In comparison cohorts, average vaccination coverage was 48%
– VE against death was 65%
▪ For children with high-risk conditions (n=153)
– 47 (31%) were vaccinated, for a VE against death of 51%
Flannery et al, Pediatrics 2017
It’s a big job; all of us will need to work on it,
together.
Public Health’s Role in Immunization
Prevention of disease
Outbreak Detection and Response
Safe and Effective Immunization
Programs
Manage SupplyInform Parental
Vaccine Decisions
Ensure Vaccine Safety
Monitor impact and strengthen evidence
base
Monitor impact and
strengthen evidence base
Parents of Young Children: Three Most Trusted Sources of Vaccine Information
2018(N = 2,506)
Percent
1 Doctor or HCP 93%
2 Scientific or medical journal 41%
3 Family members 38%
4 Prenatal care provider 36%
5 Internet or social media 18%
6 Friends 10%
7 Books 9%
8 Magazines, newspapers, radio, TV 4%
Source: CDC National Poll of Parents 2018 (unpublished data)
33
Wrapping Up
▪ Remarkable ongoing success in childhood immunization, with broad support and high coverage
▪ Current outbreaks of measles in close-knit communities require collaboration between public health and health care providers to address
▪ Room for improvement in some areas:
– HPV vaccination of pre-teens
– Adult immunization
– Influenza vaccination for all ages
▪ We know what works – the challenge is
implementation
For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Thank you
www.cdc.gov/vaccines
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