1. Insights from 26 Years in Immunization
Walter A. Orenstein
Associate Director Emory Vaccine Center
May 2004

2. Critical Lessons The ultimate goal is disease prevention
Science and program must be intimately linked
The program must be data driven with quantitative goals
Partnerships with a wide variety of public and private sector groups are needed

3. 11/22/2019
Comparison of 20th Century Annual Morbidity and Current Morbidity, Vaccine-Preventable Diseases
20th Century
Annual Morbidity†
Percent
Decrease
Disease
2003*
Diphtheria
Measles
Mumps
Pertussis
Polio (paralytic)
Rubella
Congenital Rubella Syndrome
Tetanus
H. influenzae,
type b and unknown (<5 yrs)
175,885
503,282
152,209
147,271
16,316
47,745
823
1,314
20,000‡ 1 42
197
8,483 7 14
213
99.99%
99.87%
94.24%
100%
98.93%
98.94%
Updated, 9/19/03
† Source: CDC. MMWR :
* Source: MMWR January 9, , No 53(provisional data)
‡ Data are estimated.
Numbers in yellow indicate record lows

4. Reported Measles Cases, by Age Group, U.S. 1973-1977
11/22/2019
Reported Measles Cases, by Age Group, U.S

5. Measles in 6 States Strictly Enforcing School Laws vs. Other States*
11/22/2019
Measles in 6 States Strictly Enforcing School Laws vs. Other States*
Measles incidence†
1977
1978‡
6 states
47.0
40.6
2.7
Other states
50.4
90.3
35.2
* MMWR 1978; 27:303-4
† per 100,000 < 18 years
‡ 1st 31 weeks

6. Measles Elimination Strategy
A single dose in the second year of life
Catch-up with a single dose for older unvaccinated children
Arguments against a second dose
1st dose highly effective > 95%
High cost for minimal impact
Only 2-5% of revaccinees derived benefit
Hopes that reaching high coverage with one dose would terminate transmission

7. Measles Outbreaks, United States, 1985-1986
Outbreak Classification (Age)
Preschool
(n=40)
School
(n=101)
Median (Range)
Median (Range)
Number of cases
Preventable cases (%)
Patients’ characteristics (%)
<16 mos of age
Vaccinated at >12 mos
Vaccinated at mos 13 45 32 14
(5-945)
(0-100)
(0-80)
(0-42)
(0-40) 25 27 2 60 20
(5-363)
(0-81)
(0-29)
(0-100)
N Engl J Med 1989; 320: 75-81

8. Characteristics of Counties Reporting Measles Every Year Between 1980 and 1989†
Total counties = 3137
Total, in all 10 years, with measles cases = 17 (0.5%)
Higher median population
Higher median population density
Higher proportion minority populations
Cases predominantly in unvaccinated preschoolers
Cases in counties reporting measles less frequently predominantly school-aged
† JAMA 1992; 267:

9. Polio Cases by Four-Week Period Brazil, 1975-1984*
Routine Coverage†
500
450
21%
51%
400
350
300
National Vaccination Days
Polio Cases
250
200
150
100 50
DNE-SNABS, MS, and, PAHO
†Rev Inf Dis 1984;S400-S403
Year

10. Polio Eradication Strategy
Routine immunization
National immunization days
Careful surveillance
Mop-up campaigns

11. Polio Eradication 1988 - 2003 1988 2003 779 cases* 6 countries
*As of February 4, 2004

12. Influenza Vaccine Effectiveness
Determinants
age and immune status
vaccine match
Effectiveness by age and status
< 65 years, healthy 70-90% influenza
65 years, community % influenza
65 years, nursing home 30-40% influenza
50-60% hospital
80% death
From Nancy Cox , 3/13/04

13. Differences Between Influenza and Other Vaccine Preventable Diseases
Year to year variation in viruses with differences in
Virulence
Transmissibility
Host susceptibility
Year to year variation in vaccine effectiveness

14. Estimated Annual Influenza-Associated Deaths and Influenza Coverage for Persons Aged >65 Years†
†Deaths taken from JAMA 2003; 289:
Coverage taken from U.S. Immunization Survey
National Health Interview Survey (NHIS)
Influenza: preliminary NHIS data based on Jan. - June interviews only.
Deaths are in underlying respiratory and circulatory category

15. Possible Explanations for Increasing Deaths and Coverage
Aging population
Sicker population
More H3 N2 outbreaks in the 1990’s
Lower efficacy in elderly
Non-influenza related deaths

16. Japan Influenza† 1962 – mass vaccination of school children
1977 – vaccination obligatory
Mid 1970’s to late 80’s – coverage 50-85%
1984 – law to opt out
1994 – program ended
† N Eng J Med 2001; 344:

17. Excess Deaths Attributed to Pneumonia and Influenza Over a 50 Year Period in Japan and the United States
Bars are vaccine doses/1,000 popluation
N Engl J Med 2001; 344:

18. Concerns Raised about Japanese Data†
Aging (>65 years) Japanese population – 10% – 16% 1998
Exaggerated influenza season – 6 months
Lack of age-specific data
10 fold increase in nursing homes, convalescent facilities, etc.
† N Engl J Med 2001; 344:

19. Age Specific Rates of Respiratory Illness in Tecumseh and Adrian, Michigan, During the Influenza Period
Bull WHO 1969; 41:
85.8% of students vaccinated against H2 Hong Kong in Tecumseh

20. Issues That Will Need to be Addressed
Would universal vaccination of children and young adults be effective in protecting high risk adults?
What are the benefits to the children and how do they compare to risks?
What would be the cost-effectiveness?
What is the feasibility – how can it be done?

21. Lesson 1
Vaccination of children < 2 years of life is critically important for a number of vaccine-preventable diseases
However, for some diseases, not sufficient
Must determine optimal vaccination strategy based on surveillance of disease

22. Critical Scientific Disciplines
Epidemiologic science
Vaccine science (how vaccines work, effectiveness, reasons for failure)
Vaccine safety science
Health services research
Behavioral science
Economics
Communications

23. Perceived Problems with Under-immunization: 1980s
Parents were the problem
Undervaccinated children did not have providers

24. Potential Impact of Vaccinating at all Visits*
*CDC MMWR 1994; 43(39):

25. Relationship of Maternal Beliefs at Time of Birth and Immunization Status at 7 Months†
Percent up-to-date
P value
Disease
Serious
Not
Susceptibility
Likely
Unlikely
Vaccine benefit
A lot
Little or no 28 32 30 29 23 34
>0.1
>0.1 >0.1
<0.05
† JAMA 1994; 272:

26. Physician-Estimated vs Measured Performance of 45 Practices
11/22/2019
Physician-Estimated vs Measured Performance of 45 Practices
Watt J, Smith N et al. Presented at Pediatric Academic Societies, 1998 2

27. Selected Contributions of Health Services Research
AFIX – Assessment, Feedback, Incentives, eXchange of information
Reminder/recall
Linkage with WIC

28. Insights from Communication Research
In case of pneumococcal vaccination:
There’s relatively low awareness of recommendation
And relatively high concern about “pneumonia”
In the case of influenza vaccination:
Very high awareness of influenza vaccination recommendation (e.g., 90% in Harvard survey, 2003)
Relatively high adoption or planned adoption of recommendation by those 65 and older (e.g., 82% in Roper/NFID survey, 10/2003)
Many who don’t get vaccinated have deeply held beliefs and/or are very skeptical about the value and effectiveness of influenza vaccine (e.g., Harvard, Roper/NFID survey, and Healthstyles surveys, 2003)

29. Research-based Communications

30. “What Gets Measured Gets Done”
Roger Bernier

31. Measurement of Immunization Coverage
Preschool children
Daycare attendees
School attendees
Adolescents
High risk populations

32. Goals of the Immunization Program
Healthy People 2010 goals
Need interim targets
State and local ownership
Real time information – registries ideally suited but use generally disappointing to date

33. Estimated Vaccination Coverage with the 4:3:1:3:3
Estimated Vaccination Coverage with the 4:3:1:3:3* Series, by Coverage Level and State National Coverage = 78% 69 75 84
VT 84 78 NJ CT MA NH RI DC DE MD 87 89 91 81 80 72 73 83 79 81 83 79 70 81 82 74 78 83 81 76 78 77 77 63 78 69 81 76 78 86 80 75 66 71 68 83 78 79 80
90-100% 75 68 72 79
80-89% 78
70-79%
60-69%
*4+DTP, 3+Polio, 1MCV, 3+Hib, 3+HepB
Source: National Immunization Survey, 2002
Children in the Q3/2002-Q2/2003 NIS Survey were born between August 1999 and November 2001

34. Critical Partners for Immunization
Federal, State and local governments
Manufacturers
Scientists
Provider community
Political, business, and community leaders
Minority groups
Volunteers
Educators
And more

35. The Immunization Task Children Size Infants ~4 million 1 year olds
School enterers
11-12 year olds
~16 million
Influenza
~80 million

36. Vaccines for Children Program – a Successful Public-private Partnership†
Total VFC sites 42, 313
Public sector sites 11,396
Private sector sites 30,917
† As of 2002

37. Some National Coalitions for Immunization
National Partnership for Immunization
Immunization Action Coalition
National Network for Immunization Information

38. Key Lessons for Immunization Program
Disease surveillance critical for program success – guides development of strategies
Program must be well grounded in science
Program must be data driven with measurable short term and long term goals
Success requires establishing and maintaining strong partnerships between a variety of public and private sector groups

39. EXTRA SLIDES

40. Physician-Estimated vs Measured Performance of 45 Practices
Watt J, Smith N et al. Presented at Pediatric Academic Societies, 1998