Immunizations in the United States

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Prevention of disease through the use of vaccines is one of the great success stories of public health and preventive medicine in the United States. Our success in reducing morbidity and mortality from diseases prevent able by vaccine is comparable to, or better than, that of virtually any other country in the world. Table 1 shows the maximum reported incidence of diseases preventable by vaccine, the year in which that occurred, and the

provisional total number ofcases reported in 1989. There have been reductions of 90% or more in reported mci dence of all of these diseases. Even though the 16 000 cases of measles reported in 1989 is the largest total since 1978,it still islessthan2% ofthepeaknumber.

Notwithstanding this great success, there are serious deficits in our immunization program, although the sit uation is not as bad as one might surmise from the background paper,' which does not take into account many factors such as differences in data sources, means of assessment, and surveillance systems. First, I describe the current situation, and then discuss some of the prob lems we face.

The current US immunization schedule (Table 2) calls for a total of six visits for immunization between birth and school entry. Children should receive immunization during the first year oflife, the second year, and the fifth or sixth year (just before entry to school).' Thus, the population in need of services on an annual basis is three birth cohorts, or approximately 11 to 12 million children. Recent recommendations from the American Academy of Pediatrics for a second dose of measles vaccine to be administered at approximately 12 years of age call for another visit for vaccination and increase the number of children to receive vaccine in a given year to 15 to 16 million.3 The total cost of the vaccine to immunize fully a child in the public sector is $82.90; in the private sector vaccine prices are higher, and the total cost would be more than $100.

There is no uniform data system which keeps track of all children and identifies those in need of a dose of vaccine at a particular time. More than 95% of children in this country are born in hospitals, and more than 80% of these are born in hospitals where their mothers receive

information about immunization before leaving the hos pital. This encourages them to begin the immunization series. Keeping children from falling behind in immuni zations is not systematic, however. Individual physician offices may have reminder systems, but surveys of private physician patient records demonstrate that 10% to 30% (or more) of patients are not up-to-date for immuniza tion.4'5 In the public sector, some health departments have automated systems which identify children in need of immunizations and generate reminders. In the major ity, however, there is no comprehensive system to identify and notify those who are due for vaccination.

The mechanism for delivering services to these chil dren involves both the private and public sectors. The decision about where a child will receive vaccines pri manly seems to be a financial one. Children are not allocated to one sector or another by an outside agency.

Approximately half of US children receive their im munizations from private physicians (commonly pedia tricians) as a part of their overall well child preventive care. Their parents pay for this service out of their pockets or have it paid for by third party reimbursement mechanisms. The other half receive immunizations in the public sector, often as a specific, categorical service in dependent of other preventive care services. Their par ents do not pay for the vaccine received, but they may pay a small fee for the administration. These children are likely to be members of racial or ethnic minority groups, and they are likely to be disadvantaged socioec onomically.

Since 1962 a Federal grant program has existed to give financial and technical assistance to state and local health departments to provide these immunizations to the public sector. This program is administered by the Centers for Disease Control (CDC). Grant funds typically provide approximately half of the public sector vaccines, or approximately one quarter of the national total. The level of federal support is dependent on congressional appropriation, which in turn is affected by the level of funding requested by the administration. During the past 14 years, the level of funding for the federal grant pro gram has increased dramatically, from a low of approxi mately $5 million in Fiscal Year 1976 to the current level of approximately $130 million. The striking increases are largely a reflection of the dramatic increases in vaccine prices during the 1980s, which resulted, in part, from PEDIATRICS (ISSN 0031 4005). Copyright Â©1990 by the

American Academy of Pediatrics.

1064 IMMUNIZATIONS IN UNITED STATES

Immunizationsin the United States

Alan R. Hinman, MD, MPH

From the Center for Prevention Services, Centers for Disease Control,

Atlanta,Georgia30333

at Viet Nam:AAP Sponsored on September 2, 2020 www.aappublications.org/news

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VaccineMaximum Cases (y)1989 Provisional No.Change, %Diphtheria206939 (1921)2â€”100.00Measles894134 (1941)16236â€”98.18Mumps*152209 (1968)5611â€”96.31Pertussis265 269 (1934)3 745â€”98.59Polio (paralytic)21 269 (1952)0â€”100.00Rubellat57686 (1969)373â€”99.35Congenital

rubella syndrome20 000t (1964â€”5)3â€”99.99Tetanus@601

(1948)47â€”92.18

At This Age:Your Child

ShouldReceive:2 moDTP* (first) TOPVt (first)4 moDTP (second) TOPV (second)6 moDTP (third)15 moMeasle$ Mump$ Rubella@ DTP (fourth) TOPV (third)18 moHb conjugatesAt

school entry (4-6 y)MMR, DTP (fifth) TOPV

(fourth)14â€”16 y, and every 10 yTd@lthereafter

VaccineWeighted%Head Average, Start Day

CareK-i4K-12DTP94949798Polio94949798Measles97959898Rubella97959898Mumps97959897 TABLE 1. Comparisonof Maximumand CurrentMorbidityDiseasesPreventableby

* First reportable in 1968. t First reportable in 1966.

:1:Firstreportablein 1947.

TABLE 2. RecommendedImmunizationSchedulefor Children

TABLE3. ImmunizationLevels,UnitedStates,1988to 1989 School Year

* K, kindergarten; DTP, diphtheria and tetanus toxoids and pertussis vaccine adsorbed.

Immunization coverage among children enrolled in institutions is among the highest in the world. An impor tant factor has been the enactment and enforcement of school immunization laws. The first such laws date back more than 100 years. Each state now has a law requiring immunization as a condition of entry to kindergarten or first grade at 5 to 6 years of age. In most states these laws also apply to higher grades. In all States with laws covering licensure of day care centers, the laws also apply to day care centers. Enforcement of these laws has led to attainment and maintenance of very high immunization levels in children in school or in licensed day care centers (Table 3). For nearly 10 years, 95% or more of children have had records demonstrating immunization before admission to school. Similar coverage is seen in children attending licensed day care centers. Immunization levels in these settings are high regardless of race or socioeco nomic status. When it comes to enrollment in an insti tution, virtually all barriers to immunization are over come.

These immunization levels have been associated with dramatic reductions in the incidence of diseases prevent able by vaccine. Both the data on immunization coverage and on morbidity indicate the remarkable success of immunizations in the United States. The coverage data clearly indicate that immunization services are available and are used by a very high percentage of American children. For us, the major question is: Are these services used at the appropriate time? Here our success can only be categorized as mixed.

Data in the background paper indicate low levels of immunization in preschoolers. There are some problems

* DTP, diphtheria and tetanus toxoids and pertussis vac dine adsorbed (five doses recommended).

t TOPV,trivalentoral polio vaccine(live) (four doses

recommended; however some physicians may elect to give one additional dose of TOPV at 6 mo of age).

:1:May becombinedasa singleinjectionvaccine(MMR). Â§Hb conjugate,Haemophilusb conjugatevaccine. Â¶Td, tetanusanddiphtheriatoxoidsadsorbed(adult).

HHS:PHS:CDC:CPS:IM 1/90

striking increases in liability exposure and the number of suits filed against manufacturers.6 We hope that imple mentation of the childhood vaccine injury compensation program will provide a stabilizing influence on vaccine prices.7 There is encouraging evidence that this will be the case.

Policies in the United States regarding the use of vaccines are developed in both the private and public sectors. The AAP Committee on Infectious Diseases (the Red Book Committee) is the best known of the bodies from the private sector, but the American Academy of Family Physicians and the American College of Physi cians also have committees developing immunization rec ommendations.8'9 In the public sector, the primary body is the Public Health Service's Immunization Practices Advisory Committee (ACIP).

SUPPLEMENT 1065

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with the data presented in that paper, and we think that the true levels nationwide are somewhat higher, on the order of 70% to 80% nationwide. Nonetheless, it is clear that there are areas where immunization levels are un acceptably low, where 50% or fewer of children receive measles vaccine before their second birthday. These areas tend to be lower socioeconomic areas in our larger cities, and the unvaccinated children tend to be members of racial or ethnic minority groups. For example, a survey was carried out last month in Chicago schools, where essentially all children had records of having received measles vaccine (Immunization Division, Centers for Dis ease Control. Unpublished data). The survey looked at the age at which these pupils had received measles vac cine and compared results in schools which were predom inantly white, predominantly black, and predominantly

Hispanic. In the predominantly white schools,which tendedto be in middle-classareas,80% of studentshad

received measles vaccine before their second birthday. By contrast, in both the predominantly Hispanic and the predominantly black schools, which tended to be in lower socioeconomic areas, only approximately 50% of pupils had received measles vaccine before their second birth day. Few students in the predominantly white schools delayed receipt of vaccine until after the age of 4 years,

whereas approximately one quarter of students in pre dominantly black or Hispanic schools were vaccinated at that age, probably to meet school immunization require ments. Not surprisingly, measles attack rates were cor related inversely with the proportion of schoolchildren who had received measles vaccine before their second birthday.

There are many factors involved in this problem, and it is not possibleto assignrelative weightsto them. One of the factors clearly is the presence of financial barriers for the 6 to 8 million uninsured children, particularly in areas where health department facilities are not widely distributed. Second, there may be bureaucratic impedi ments for those who are Medicaid-eligible but not yet enrolled. A third relates to the accessibility of services, whether private or public. In this category I include both geographic and temporal accessibility. In addition, there may be administrative obstacles even when services are available. Fourth, many parents are unaware of the im portance of immunizations or have so many other im mediate priorities that a preventive measure simply does not compete successfully. Absence of a comprehensive

reminder system aggravates this problem. Outreach ef forts to make immunization relevant are often not pos sible. Fifth, even when children are taken to a health care facility, providers may miss opportunities to provide vac cine by not reviewing immunization status, by not pro viding all needed antigens at a single visit, or by adhering to an excessivelist of contraindications.Finally,thereis incomplete coordination between separate programs deal ing with the same population, eg, WIC, AFDC, and health departments. We have been fortunate in receiving funds this year for an Infant Immunization Initiative, which is designed specifically to obtain more information about the relative importance of these factors and to provide guidance for solving some of these problems.

Progress in controlling disease through immunization in the United States has been remarkable. Few, if any, countries have attained greater success. Nonetheless, se rious problems remain in our ability to bring the benefits of immunization to all infants and children at the appro priate time. I hope the presentations and discussions at this Conference will provide important guidance for us to improve the situation.

REFERENCES

1. Williams BC. Immunization coverage among preschool chil then: The United States and selected European countries.

Pediatrics. 1990;86(suppl):1052â€”1056

2. Centers for Disease Control. Recommendations of the Im munization Practices Advisory Committee (ACIP): General recommendations on immunization. MMWR. 1989;38:205â€” 214, 219â€”227

3. Committee on Infectious Diseases, American Academy of Pediatrics. Measles: reassessment of the current immuni zation policy. Pediatrics. 1989;84:1110â€”1113

4. McDaniel DB, Patton EW, Mather JA. Immunization ac

tivities of private-practice physicians: a record audit. Pedi atrics. 1975;56:504â€”507

5. Ector WL. Immunization levels of children in private prac tice. In: Centers for Disease Control. Proceedings of the 15th Immunization Conference. 1980:70â€”72

6. Hinman AR. DTP vaccine litigation. AJDC. 1986;140:528â€” 530

7. Clayton EW, Hickson GB. Compensation under the Na tional Childhood Vaccine Injury Act. J Pediatr.

1990:116:508â€”513

8. American Academy of Family Physicians. Immunization

Guidelines. Kansas City MO: American Academy of Family

Physicians; October 1988:Part 1

9. American College of Physicians. Guide for Adult Immuni

zation. Philadelphia: American College of Physicians; 1990

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1990;86;1064

Pediatrics

Alan R. Hinman

Immunizations in the United States

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Pediatrics

Alan R. Hinman

Immunizations in the United States

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