1. Overview of National Surveillance for Vaccine-Preventable Diseases
Sandra W. Roush, MT, MPH
Surveillance Officer
National Center for Immunization and Respiratory Diseases (proposed)
Centers for Disease Control and Prevention
phone:
March 2007

2. Objectives for VPD Surveillance
Estimate burden of disease, severity, complications
Determine geographic distribution of illness
Portray the natural history of a disease
Detect epidemics/define a problem
Generate hypotheses, stimulate research
Evaluate control measures, monitor use of vaccine
Monitor changes in infectious agents
Detect changes in health practices
Facilitate planning

3. Numbers in yellow indicate at or near record lows in 2005
Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases
Disease
20th Century
Annual Morbidity†
2005††
Percent Decrease
Smallpox
48,164
100%
Diphtheria
175,885
Measles
503,282 66
> 99%
Mumps
152,209
314
Pertussis
147,271
25,616
83%
Polio (paralytic)
16,316 1*
Rubella
47,745 11
Congenital Rubella Syndrome
823 1
Tetanus
1,314 27
98%
Haemophilus influenzae
20,000
226**
99%
†Source: CDC. MMWR April 2, :
† †Source: CDC. MMWR. August 18, 2006 / 55(32);
* Imported vaccine-associated paralytic polio (VAPP)
** Type b and unknown (< 5 years of age)
Numbers in yellow indicate at or near record lows in 2005

4. Pre-Vaccine Era Estimated Annual Morbidity †
Comparison of Pre-Vaccine Era Estimated Annual Morbidity and Current Estimated Morbidity: Vaccine-Preventable Diseases
Disease
Pre-Vaccine Era Estimated Annual Morbidity †
2005 Estimated
Morbidity †
Percent Decrease
Hepatitis A
117,333
19,183
84%
Hepatitis B (acute)
66,232
15,352
77%
Pneumococcus (invasive)
all ages
63,067
40,325
36%
< 5 years of age
16,069
4,400
73%
Varicella
4,085,120
817,024
80%
† Unpublished CDC data, reported November 2006

5. Epic Surveillance Questions
What does the data mean?
Does ZERO mean ZERO?
Can we describe the strengths and challenges of the surveillance system?
Are there vaccine failures?
Are the reported cases really cases?

6. Critical Elements in National Surveillance for VPDs
Demographic data
Clinical history
Vaccination history
Laboratory testing, confirmation, and molecular epidemiology
Role of importation

7. Surveillance Indicators
Developed in 1988 by PAHO for polio eradication effort
surveillance infrastructure
timeliness of reporting
adequacy of case investigation
appropriateness of laboratory testing and diagnostic effort
Concept for US VPD surveillance indicators approved by CSTE in 1994
initially applied to measles
currently for measles, rubella, mumps, pertussis, H. influenzae type b; adding meningococcal disease and varicella

8. Applied Vaccine-Preventable Disease Surveillance Indicators
External standard for infrastructure:
polio and acute flaccid paralysis
Haemophilus influenzae type b
Appropriateness of testing/diagnostic effort:
proportion of cases meeting the clinical case definition that is lab confirmed
Adequacy of case investigation:
measles/rubella with an imported source
complete vaccination history

9. Use of Case Definitions in VPD Surveillance
Assure comparability among states and year-to-year
May not be the same definitions a clinician would use
Are not used to determine the need for public health action

10. Haemophilus influenzae type b (Hib) Invasive Disease National Surveillance

11. Haemphilus influenzae Incidence* Per 100,000 Children <5 years,
By Year and Serotype,
*From CDC’s Active Bacterial Core surveillance (ABCs)

12. * National Notifiable Diseases Surveillance System
Haemophilus influenzae Serotype Reporting, Children < 5 Years, NNDSS*
Percent
Year
* National Notifiable Diseases Surveillance System

13. Enhancing Surveillance for H. influenzae
Serotyping on sterile site isolates from children
Obtaining vaccination history
Improving case ascertainment
Hospital based reporting
Laboratory based reporting
Tracking non-type b invasive disease

14. Pertussis National Surveillance

15. Reported Pertussis Cases,
DTP

16. Challenges – Pertussis
Vaccine effectiveness against classic pertussis ~85% among infants (lower for mild disease); inferred for adolescents and adults
Immunity wanes years after vaccine and infection
Pertussis increased activity typically occurs in 3 – 5 year cycles; challenge for research and maintaining infrastructure
No well-accepted correlates of protection; role of CMI not defined
Laboratory diagnostics not available for practitioners or to support surveillance

17. * Week 52 provisional data, NNDSS
Percent Completeness of Pertussis Vaccine History National Notifiable Diseases Surveillance System (NNDSS)
Percent
Year
* Week 52 provisional data, NNDSS

18. * Week 52 provisional data, NNDSS
Percent of Cases with Laboratory Testing Among Those Meeting Pertussis Clinical Case Definition, NNDSS
Percent
Year
* Week 52 provisional data, NNDSS

19. Pertussis Surveillance and Policy Priorities
Define age-specific incidence, trends in pertussis to monitor the effectiveness of the vaccination program
Determine Tdap effectiveness against pertussis and transmission
Define factors contributing to severe pertussis among adults
Enhance surveillance (e.g., cough duration, laboratory confirmation, vaccination history)

20. Streptococcus pneumoniae Surveillance

21. National Surveillance for Invasive S. pneumoniae
1994: DRSP under national surveillance
2000: invasive pneumococcal disease in children < 5 years under national surveillance
Assess impact of PCV7
For states, raise awareness of vaccine recommendations and identify areas with sub-optimal vaccine use
Complement DRSP surveillance
Evaluate impact of campaigns for judicious antibiotic use
2006: Enhance national surveillance

22. National Reporting for Invasive S. pneumoniae < 5 Years
No clear relationship between PCV7 coverage and rates of reported cases
No invasive S. pneumoniae (ISP) < 5 years reported from 9 states during 2005 and 2006
State case reporting for 2005
30 states/DC reported 2,996 cases of DRSP
35 states/DC reported 1,495 cases of ISP < 5 years of age

23. Remaining Questions for S. pneumoniae Surveillance
Will replacement disease become more of a problem?
What is the effect on pneumonia?
How will results in other settings compare?
How can CDC and state partners assess the impact PCV7 vaccination with differential coverage both within and between states?

24. Measles, Rubella, and Mumps National Surveillance

25. Healthy People 2010 (HP 2010) Objectives
Eliminate Indigenous Cases of:
Target Congenital Rubella
Syndrome
Measles
Mumps
Rubella

26. Measles – United States, 1950-2005
2004 – –66
Vaccine Licensed 1963
1st Elimination Goal
Endemic
Elimination
Declared
2nd Goal
2 Doses
3rd Goal
*2005 provisional data

27. Rubella - United States, 1966-2005
CRS:
2005 – 1
Vaccine First Licensed 1969
2004 –10
2005 –11
Current Vaccine Licensed 1979
Elimination Goal
Endemic
Elimination
Declared
Reduction
Goal
*2005 provisional data

28. Number and Percent of Imported Measles Cases, United States, 1985 - 2005
* Includes Imported, imported-linked, and imported virus cases

29. Mumps – United States,
Mumps Vaccine licensed 1967 20 40 60 80
100
120
140
160
1968
1972
1976
1980
1984
1988
1992
1996
2000
2004
Cases (thousands)
Routine childhood recommendation 1977
2 dose MMR

30. Mumps Vaccination Program Goal and Surveillance
HP 2010 – Eliminate indigenous transmission
Passive surveillance: < 300 cases/year since 2001 (until 2006) (Elimination??)
Surveillance indicators
Median days symptom onset to report 4-11 days
42%-57% of cases were confirmed
Few viral isolates for molecular typing prior to 2006 (~ 1-2 per year since )
Occasional clusters 2-3 epi-linked cases (until 2006)

31. Mumps Cases Reported by States,
January 1 – September 2, 2006 (N=5,587)1
750
287
355
1956
574
880
155 8
< 25 cases
cases
cases
cases
cases
cases
1 Reported through the National Notifiable Diseases Surveillance System (data provisional).

32. Enhancing Mumps Surveillance
Obtain laboratory confirmation
May include serology, viral culture, or PCR
In 2004: 37 % were lab confirmed, 57 % were reported as “confirmed”
Obtain vaccination history
Obtain viral isolates for molecular epidemiology; molecular typing available at CDC
Lab challenges: in vaccinees, can not rule out cases based on negative IgM

33. Varicella National Surveillance

34. Pre-Vaccine Annual Disease Burden
4 million cases
10,500-15,000 hospitalizations
deaths
Risk factors for severe disease: extremes of age, immune deficiency
Significant societal health burden

35. Varicella Vaccination Program Goals
No program goal set at the beginning of the program
Healthy People 2010 Goals, published in 1998
90% reduction in varicella ( ,000 cases)
90% vaccination coverage among month olds
90% coverage among adolescents

36. Antelope Valley West Philadelphia
Reported varicella cases and vaccination coverage* by year Varicella Active Surveillance Project,
Antelope Valley
West Philadelphia
Vaccination coverage
Varicella cases
*Coverage estimates from NIS in LA and Philadelphia, among children
19-35 months of age.

37. Challenges for Varicella Prevention
Vaccine 80%-85% effective (1 dose)
Vaccinated cases are infectious
Diagnostic challenges for breakthrough disease (may be mild and atypical)
Varicella outbreaks among highly vaccinated school children (coverage 96%-100%)
Shift in age of cases but no increase in incidence among adults

38. Challenges for Varicella Surveillance
Improve reporting and surveillance
25 states report varicella
31 states have case-based reporting
32,242 cases reported in 2005
Implement and improve case-based reporting with phased approach
Focus: age, vaccine history, severity
Sentinel sites, then statewide

39. Resources for Surveillance Support
VPD Surveillance Manual
VPD Surveillance Satellite Course
Web links:
Pertussis outbreak guide
Varicella outbreak guide
CSTE web site
Immunization Program Operations Manual
State Immunization Program Manager, State Epidemiologist, NNDSS state coordinator
NCIRD surveillance officer

40. THANK YOU ! Sandra W. Roush, MT, MPH Surveillance Officer
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
phone: