Reported Vaccine-Preventable Diseases -- United States, 1993, and the Childhood Immunization Initiative

In the United States, children are routinely vaccinated against nine diseases -- diphtheria, Haemophilus influenzae type b (Hib), hepatitis B, measles, mumps, pertussis, poliomyelitis (paralytic), rubella, and tetanus (1). Based on public health surveillance and epidemiologic assessment of most of these diseases, the impact of childhood vaccination on reported occurrence has been substantial (2,3): provisional surveillance data for 1993 indicate that for five of these diseases and for congenital rubella syndrome (CRS), the number of reported cases is at or near the lowest levels ever, suggesting near interruption of transmission of these diseases. This report presents provisional data for December 1993 for these 10 diseases, compares provisional data for 1993 with final data for 1992, and describes the Childhood Immunization Initiative (CII).

In December 1993, state health departments reported no cases of CRS, diphtheria, or poliomyelitis, and fewer than five cases each of measles and tetanus (Table_1). In addition, no cases of indigenously acquired measles were reported that could not be linked to chains of transmission from known imported cases during September-December, the longest such period since surveillance began in 1912.

Provisional data for 1993 indicate that the numbers of reported cases of CRS, diphtheria, measles, poliomyelitis, rubella, and tetanus were at or near the lowest levels ever (Table_1). Marked differences were observed in the age-specific incidence of invasive H. influenzae disease, * acute hepatitis B, mumps, and pertussis; the number of persons with reported cases for whom age was known was 1211, 11,633, 1515, and 5793, respectively. For invasive H. influenzae disease, preschool-aged (aged less than 5 years) children constituted 399 (33%) cases; for acute hepatitis B, 142 (1% **); for mumps, 275 (18%); and for pertussis, 3753 (65%). Of preschool-aged children with pertussis, 2549 (68%) were aged less than 1 year (4). Reported by: National Immunization Program, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that the incidences of most vaccine-preventable diseases during 1993 were at or near their lowest reported levels. However, decreases in disease burden and mortality can be sustained only by achieving and maintaining high vaccination levels among children aged 0-2 years. For example, although the incidence of measles was low during 1981- 1988, during 1989-1991, a resurgence of measles -- attributed primarily to a failure to vaccinate preschool-aged children on time (i.e., early during the second year of life) (5) -- accounted for an estimated 55,000 measles cases, 11,000 hospitalizations, and 130 deaths (CDC, unpublished data, 1993).

The national response to the resurgence of measles has improved vaccination coverage among children aged 0-2 years. However, because no system has been fully established to ensure that all children complete the recommended series of 11-15 doses of vaccine by their second birthday, vaccination coverage remains unacceptably low in many areas of the United States (1,6). In 1993, the President initiated CII, a more comprehensive national response to undervaccination. The goals of CII are to 1) eliminate indigenous cases of six vaccine-preventable diseases (i.e., diphtheria, Hib disease {among children aged less than 5 years}, measles, poliomyelitis, rubella, and tetanus {among children aged less than 15 years} by 1996 ***; 2) increase vaccination coverage levels to at least 90% among 2-year-old children by 1996 for each of the vaccinations recommended routinely for children (for hepatitis B, the objective is set for 1998) (Table_2); and 3) establish a vaccination-delivery system that maintains and further improves high coverage levels.

CII comprises six broad areas of activity that constitute the framework for meeting the nation's goals for 1996 and beyond:

• Improve quality and quantity of vaccination-delivery services. State and local health agencies will use new federal resources to hire personnel, extend clinic hours, and encourage health-care providers to use all health-care contacts to administer needed vaccines and reduce obstacles parents encounter in obtaining vaccinations for children (7). Computerized state vaccination information systems are being developed to remind parents when vaccinations are due and to assist health-care providers in determining the vaccination needs of patients.

• Increase community participation and education. A long-term, national outreach campaign will be initiated in April 1994 to improve parent awareness of the need for timely childhood vaccination and to prompt health-care providers to use all health-care contacts to administer needed vaccines to children. At the national level, elements of this campaign will include widespread distribution of radio, television, and print public service announcements; dissemination of a national theme and call to action; and other activities designed to unify efforts throughout the country. At the state and community levels, the campaign will include a grass roots organizing effort to unite all sectors of the community (e.g. public and private health-care providers, business groups, community leaders, minority groups, voluntary and service organizations, religious institutions, and media affiliates).

• Reduce vaccine cost for parents. To reduce vaccine cost as a barrier to vaccination, the U.S. Department of Health and Human Services will initiate the Vaccines for Children program on October 1, 1994. This program will purchase vaccines from manufacturers and provide them at no cost to participating public and private health-care providers for use in children aged 0-18 years who are eligible for Medicaid, are without health insurance, or are American Indian. Children with health insurance who are served by federally qualified health centers also will be able to receive free vaccine if their insurance does not cover vaccination. State vaccination programs will be permitted to purchase additional vaccines at reduced federal contract prices.

• Improve surveillance for coverage and disease. An improved system for measuring vaccination coverage at the national, state, and local levels among infants and young children is being established to identify undervaccinated populations and to monitor progress in achieving coverage goals. Clinic or office-based assessments are being completed to assist health-care providers in increasing coverage among the populations they serve. Surveillance for vaccine-preventable diseases will be intensified by investigating each case of disease targeted for elimination to determine how that case might have been prevented and enable initiation of aggressive control measures when cases are detected.

• Form and strengthen partnerships. Many federal agencies provide vaccinations to children, reimburse for vaccination services, or have access -- through education, food, housing, or other assistance -

1. to populations at high risk for undervaccination. Similarly, many private providers and organizations vaccinate children or otherwise serve or advocate for children. Coordination of these efforts will be strengthened and new partnerships formed to concentrate the efforts of these providers and organizations on improving the vaccination of children.

• Improve vaccines. Emphasis will be placed on the development and licensure of new and safer or more effective vaccines. Existing vaccination schedules will be simplified, and development of combination vaccines will be promoted.

To track progress toward achieving the goals of CII, CDC's National Immunization Program is initiating in this issue of MMWR monthly publication of a table that summarizes the number of cases of all diseases preventable by routine childhood vaccination reported during the previous month and year-to-date (provisional data) (Table_1). In addition, the table compares provisional data with final data for the previous year and highlights the number of reported cases among children aged less than 5 years -- who are the primary focus of CII. Data in the table are derived from CDC's National Notifiable Diseases Surveillance System.

References

1. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1994;43(in press).

2. Orenstein WA, Atkinson W, Mason D, Bernier RH. Barriers to vaccinating preschool children. J Health Care Poor Underserved 1990;1:315-30.

3. Adams WG, Deaver KA, Cochi SL, et al. Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era. JAMA 1993;269:221-6.

4. CDC. Resurgence of pertussis -- United States, 1993. MMWR 1993;42:952-3,959-60.

5. National Vaccine Advisory Committee. The measles epidemic: the problems, barriers, and recommendations. JAMA 1991;266:1547-52.

6. CDC. Vaccination coverage of 2-year-old children -- United States, 1991-1992. MMWR 1993; 42:985-8.

7. CDC. Standards for pediatric immunization practices. JAMA 1993;269:1817-22. * H. influenzae serotype is not routinely reported to the National Notifiable Diseases Surveillance System. ** Because most hepatitis B virus infections among infants and children aged less than 5 years are asymptomatic (although more likely to become chronic), acute disease surveillance does not reflect the incidence of this problem in this age group or the effectiveness of hepatitis B vaccination in infants. *** Objectives to reduce cases of mumps, pertussis, and hepatitis B will be set during 1994.

Table_1
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TABLE 1. Number of reported cases of diseases preventable by routine childhood
vaccination -- United States, December 1993 and 1992-1993 *
====================================================================================================
                                                                      No. cases among children
                      No. cases,            Total cases                   aged <5 years +
                       December        ----------------------         ------------------------
Disease                  1993            1992            1993             1992        1993
----------------------------------------------------------------------------------------------
Congenital rubella
 syndrome (CRS)             0               9               7                9           5 &
Diphtheria                  0               3               0                1           0
Haemophilus
 influenzae @             135           1,412           1,264              592         399
Hepatitis B **          1,330          16,126          12,396              215         142
Measles                     4           2,231             281            1,116         104
Mumps                     157           2,485           1,640              364         275
Pertussis                 700           3,935           6,335            2,261       3,753
Poliomyelitis,
 paralytic ++              --              --              --               --          --
Rubella                    11             157             195               24          36
Tetanus                     4              44              43                0           1
----------------------------------------------------------------------------------------------
 * Data for 1992 are final and for 1993, provisional.
 + For 1992 and 1993, age data were available for 90% or more cases, except for 1992 age
   data for mumps and rubella, which were available for 84% and 64% of cases, respectively.
 & Age reported for five of seven persons with CRS through December 31, 1993.
 @ Invasive disease; H. influenzae serotype is not routinely reported to the National Notifiable
   Diseases Surveillance System.
** Because most hepatitis B virus infections among infants and children aged <5 years are
   asymptomatic (although likely to become chronic), acute disease surveillance does not
   reflect the incidence of this problem in this age group or the effectiveness of hepatitis B vac-
   cination in infants.
++ Four cases of suspected poliomyelitis were reported in 1993; four of the five suspected
   cases with onset in 1992 were confirmed, and the confirmed cases were vaccine-associated.
====================================================================================================

TABLE 2. Vaccination coverage levels targeted by the objectives for the Childhood
Immunization Initiative, by vaccine and year * -- United States
===================================================================================
 Vaccine                         1992 Baseline +   1994       1995       1996
------------------------------------------------------------------------------
 Diphtheria and tetanus toxoids
  and pertussis (3-4 doses)           83%          85%        87%        90%
 Poliomyelitis (3 doses)              72%          75%        85%        90%
 Measles-mumps-rubella (1 dose)       83%          85%        90%        90%
 Haemophilus influenzae
  type b (3-4 doses)                  --           75%        85%        90%
 Hepatitis B (3 doses)                --           30%        50%        70% &
------------------------------------------------------------------------------
* Baseline data for 1993 are not yet available.
+ Baseline data from 1992 National Health Interview Survey (6).
& The goal is for 90% vaccination coverage by 1998.
===================================================================================

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