Anne Schuchat, MDDirector, National Center for Immunization and Respiratory

DiseasesAssistant Surgeon General, US Public Health Services

Centers for Disease Control and Prevention

CDC Update on Achieving Healthy People 2020 Objectives for Immunization and Vaccine-

Preventable Diseases

National Center for Immunization and Respiratory Diseases

NVAC Meeting, September 10, 2014Washington, DC

Outline Update on immunization & vaccine-

preventable disease objective progress Selected barriers Product issues Consumer and patient issues Provider and system issues

Summary and discussion

MMWR 63(16);352-355, April 25, 2014

Increasing Vaccine-Specific Coverage Rates Among Preschool-Aged Children: 1967 - 2013

Children 19-35 Months Who Received No Vaccinations, 2008-2013, U.S.

0.6 0.60.7

0.8 0.80.7

0

1

2

2008 2009 2010 2011 2012 2013

% z

ero

vacc

inat

ions

Survey Year

HP2020 Goal: <1%

MMWR 63(34); 741-748, August 29, 2014

HP2020 objective IID-9 (tracking measure)

Estimated Vaccinat ion Coverage, Children 19-35 Months,

New Healthy People 2020 Object ives

* HP2020 target for birth dose of HepBis measured by birth cohort. Data shown are estimates from the 2005-2010 birth cohorts.** 2 or 3 doses, depending on the type of rotavirus vaccine receivedSource: CDC, NIS

National Center for Immunization & Respiratory DiseasesHistorical Comparisons of Vaccine-Preventable Disease Morbidity in the U.S.

Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases

Disease20th Century

Annual Morbidity†2013

Reported Cases † †Percent

Decrease

Smallpox 29,005 0 100%Diphtheria 21,053 0 100%Measles 530,217 187 > 99%Mumps 162,344 584 > 99%Pertussis 200,752 28,639 86%Polio (paralytic) 16,316 1 > 99%Rubella 47,745 9 > 99%Congenital Rubella Syndrome 152 1 99%Tetanus 580 26 96%Haemophilus influenzae 20,000 31* > 99%† JAMA. 2007;298(18):2155-2163† † CDC. MMWR August 15, 2014:63(32);702-715. (MMWR 2013 final data) * Haemophilus influenzae type b (Hib) < 5 years of age. An additional 10 cases of Hib are estimated tohave occurred among the 185 reports of Hi (< 5 years of age) with unknown serotype.

8/28/14

National Center for Immunization & Respiratory DiseasesHistorical Comparisons of Vaccine-Preventable Disease Morbidity in the U.S.

Comparison of Pre-Vaccine Era Estimated Annual Morbidity with Current Estimate: Vaccine-

Preventable Diseases

DiseasePre-Vaccine Era Annual

Estimate†2013 Estimate* Percent

Decrease

Hepatitis A 117,333 2,890 98%Hepatitis B (acute) 66,232 18,800 72%Pneumococcus (invasive)

all ages 63,067 33,500 47%< 5 years of age 16,069 1,900 88%

Rotavirus (hospitalizations, < 3 years of age)

Varicella

62,500 *

4,085,120

12,500

167,490

80%

96%

† JAMA. 2007;298(18):2155-2163* CDC (NNDSS, ABCs/EIP Network, NVSN)

8/28/14

0.0

5.0

10.0

15.0

20.0

25.0

2008 2009 2010 2011 2012 2013

Case

s per

100

,000

pop

ulat

ion

Year

<5 Overall

<5 Antibiotic-resistant<5 Overall

<5 Antibiotic-resistant

HP2020 Target: 12

PCV13 introductionHP2020 Target: 6

Incidence of Invasive Pneumococcal Disease (IPD) in Children <5 years old

Source: CDC (Active Bacterial Core Surveillance, EIP Network)

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

2008 2009 2010 2011 2012 2013

Case

s per

100

,000

pop

ulat

ion

Year

65+ Overall

65+ Antibioitc-resistant

HP2020 Target: 31

HP2020 Target: 9

PCV13 introduction

Incidence of Invasive Pneumococcal Disease (IPD) in Adults > 65 years old

Source: CDC (Active Bacterial Core Surveillance, EIP Network)

http://www.cdc.gov/vaccines/acip/meetings/slides-2014-08.html

Product-related issues

National Center for Immunization & Respiratory Diseases

0

50,000

100,000

150,000

200,000

250,000

300,000

Num

ber o

f cas

es

Year

DTP

0

10,000

20,000

30,000

40,000

50,000

60,000

1990 1995 2000 2005 2010 2013

Tdap

DTaP

Reported NNDSS Pertussis Cases: 1922-2013

SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service

Trends in Pertussis by Age Group

0

2000

4000

6000

8000

10000

12000

14000

16000

2012 2013* 2012 2013*

HP2020 Target: 2000

<1 year 11-18 years

HP2020 Target: 2500

*MMWR 62(52); ND-719-ND-732 (provisional, week 522013 NNDSS data) 9-5-14

DTaP Effectiveness (California, 20101) and Tdap Effectiveness (Washington, 20122)

by Time Since Last Dose*

0102030405060708090

100

0-1 1-2 2-3 3-4 (2-4 forTdap)

4-5 >5

Vacc

ine

Effe

ctiv

enes

s (VE

)*

Years Since Vaccinat ion

DTaP VE Tdap VE

1JAMA. 2012;308:2126-2132. *Accounting for clustering by county and provider2CDC, unpublished data.

Improving Vaccination during Pregnancy is Key

Amirthalingam, Lancet, July 16, 2014 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960686-3/fulltext

15

Estimated Herpes Zoster (Shingles)Vaccination Coverage, Adults aged > 60 years

0

10

20

30

40

2008 2009 2010 2011 2012

% Z

oste

r Cov

erag

e

Year

HP2020 at least 30%

National Health Interview Survey

Major Supply Constraints in Past 5 Years

Hib vaccine shortage:Dec. 2007-July 2009

Zoster vaccine shortage:2009-Dec. 2011

Pentacel combinat ion vaccine shortage:Apr. 2012- May/June 2014

Consumer and Patient-related issues

National Center for Immunization & Respiratory Diseases

Measles in the U.S. has reached a 20-year high

*2014 data reported as of August 29, 2014 19

Reported Measles Incidence United States, 1992-2014*

0.00.10.20.30.40.50.60.70.80.91.0

1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

Cases/100,000

Year

*YTD

1 case/million

Measles elimination declared

*As of September 2, 2014

Provider and system issues

National Center for Immunization & Respiratory Diseases

National Vaccination Coverage Levels Adolescents 13-17 Years,

NIS-Teen, 2006-2013

0

20

40

60

80

100

2006 2007 2008 2009 2010 2011 2012 2013

Perc

ent

Year

Tdap

MenACWY

>1 HPV (girls)

>3 HPV (girls)>3 HPV (boys

> 3 H P V ( b o y s )

MMWR. 2014;63;625-33

22

Vaccination Coverage, Adolescents 13-15 years, 2006-2013

NIS-Teen

≥1 Tdap

≥1 MCV

≥3 HPVfemales only

0

10

20

30

40

50

60

70

80

90

100

2006 2007 2008** 2009 2010 2011 2012 2013

Perc

ent ≥1 HPV*

females only

Varicella

HP 2020 Target*

* Target is 90% for 2 doses of varicella; > 1 HPV is not an HP 2020 objective. ** Baseline for HP 2020.

Actual and potent ially achievable vaccinat ion coverage of >1 HPV vaccine by age 13 years among adolescent girls if missed

opportunit ies* were eliminated, NIS-Teen 2007-2013 combined

12

28 32 34 3642

47

20

57

7480

85 88 91

0

20

40

60

80

100

1994 1995 1996 1997 1998 1999 2000

% v

acci

nate

d

Year of Birth

Actual Coverage

Potential Coverage

*Missed opportunity defined as having a healthcare encounter where at least one vaccine was administered but HPV was notMMWR. 2014; 63:620-4

Healthy People 2020 Objective 17.1Increase percentage of public health providers who have had vaccination coverage levels among children in their practice

population measured in the past year

0%

10%

20%

30%

40%

50%

60%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Healthy People 2020 Target

70%

25

Healthy People 2020 Objective 17.2Increase percentage of private providers who have had

vaccination coverage levels among children in their practice population measured in the past year

0%

10%

20%

30%

40%

50%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Healthy People 2020 Target

60%

26

60%

65%

70%

75%

80%

85%

90%

95%

100%

2006 2007 2008 2009 2010 2011 2012 2013

IID-18 Increase the percentage of children under the age of 6 years of age whose immunization records are in a

fully operational, population-based immunization information system (IIS)

27

Immunization Information System Executive Board First meeting held Nov 19, 2013

Newly chartered inter-governmental board Federal, state, and local governmental members Provides input to CDC to help update IIS strategic plan Helps NCIRD sustain nat ional leadership role in future

direct ion of IIS Assists us with development and alignment of strategic

init iat ives to support goals Strengthens links with key governmental stakeholders

and enablers (Office of the Nat ional Coordinator, CMS,Indian Health Service, cancer registries, etc.)

CDC’s IIS Strategic Plan Focus Areas

National leadership Vision, strategy, policy, standards, accountability, shared services

Service Delivery Provider/patient access & clinical decision support at point of care

Capacity & Infrastructure Immunization programs, informatics, surveillance, coverage

Interoperability/data management Data exchange across information ecosystem, including data

quality & semantic interoperability considerations

Sustainability Long-term funding, resources to maintain immunization

information management and informatics at a national level

Changes in HP2020 Objectives

• Influenza objectives have been consolidated and datasources updated– http://www.healthypeople.gov/2020/topicsobjectives2020/ob

jectiveslist.aspx?topicid=23

• HPV objective for boys has been approved– Eventually, aim for HPV objective for all teens (girls and boys)

30

Summary for 2013/14 HP2020

• Most VPDs low or decreasing– Sustained or improved immunization coverage– Measles in 2014 and pertussis cycles

• Current barriers and challenges– Reducing pertussis deaths through Tdap in

pregnancy– Intermittent supply shortages– Public and provider barriers

• Measles among selected groups (e.g. Amish)• HPV vaccination issues (missed opportunities)

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Acknowledgments

Kafayat AdeniyiJoseph AlcoberBrooke BarryAmanda CohenRebecca GoldMarsha HoustonHelen Kuykendall

Karen MasonKristin PopeSandra RoushJames SingletonShannon StokleyCandice SwartwoodNatarsha Thompson

32