National Center for Immunization & Respiratory Diseases

Immunization Update:National Perspective

Melinda Wharton, MD, MPH

Director, Immunization Services Division

Texas Immunization Conference

Dallas, TexasOctober 25, 2019

Disclosures

▪ I work for the Centers for Disease Control and Prevention

▪ I have no financial interests to disclose

▪ I will not be discussing investigational products or off-label uses of vaccines

Learning Objectives

▪ Describe current trends in vaccine coverage in the United States

▪ Identify at least one strategy to improve vaccine coverage that you can implement in your practice or work setting.

Vaccines remain one of the most effective ways for protecting babies, children, and adults from

disease, disability, and death.

Comparison of 20th Century Annual Morbidity and Current Morbidity:

Vaccine-Preventable Diseases

Disease

20th Century

Annual Morbidity†

2018

Reported Cases † †

Percent

Decrease

Smallpox 29,005 0 100%

Diphtheria 21,053 1 > 99%

Measles 530,217 273 > 99%

Mumps 162,344 2,251 99%

Pertussis 200,752 13,439 93%

Polio (paralytic) 16,316 0 100%

Rubella 47,745 5 > 99%

Congenital Rubella Syndrome 152 0 100%

Tetanus 580 20 97%

Haemophilus influenzae 20,000 27* > 99%

† JAMA. 2007;298(18):2155-2163† † CDC. MMWR January 6, 2017/ 65(52);ND-924 – ND-941. (MMWR 2016 week 52 provisional data)

* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 11 cases of Hib are estimated to

have occurred among the 221 reports of Hi (< 5 years of age) with unknown serotype.

Childhood Immunization Provides Big SavingsVaccines for Children: 25 years of protecting America’s children

CDC estimates that vaccination of children born between 1994 and 2018:

▪ Prevent 419 million illnesses

▪ Prevent 26.8 million hospitalizations

▪ Help avoid 936,000 early deaths

▪ Save nearly $406 billion in direct costs and $1.88 trillion in total society costs

▪ Every dollar spent in childhood vaccination ultimately saves $10.10.

Updated data from previous article: Benefits from Immunization During the Vaccines for Children Program Era – United States, 1994-2013. MMWR. 25 April 2014

Nationally, vaccination of young childrencontinues to be the norm.

Vaccine-specific coverage among children 19-35 months, National Immunization Survey-Child, 1994-2017

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nt

Vac

cin

ate

dHib-FS

Vaccination Coverage Among Children Aged 19-35 Months -- United States, 2017Additional information on vaccination coverage estimates and interpreting trendsAbbreviations: MMR = measles, mumps, and rubella vaccine; DTP/DTaP = diphtheria and tetanus toxoids and pertussis vaccine / diphtheria and tetanus toxoids and acellular pertussis vaccine; Hib = Haemophilus influenzae type b vaccine; FS = full series; HepB = hepatitis B vaccine; PCV = pneumococcal conjugate vaccine; HepA = hepatitis A vaccine

3+ HepB

1+ Varicella

4+ PCV

3+ Hib Rotavirus

2+ HepA

1+ MMR

4+ DTP/DTaP

3+ DTP/DTaP

3+ Polio

SUPPLEMENTARY FIGURE 1. Estimated Vaccination Coverage by Age 24 Months, by Birth Year, National Immunization Survey-Child 2012-2018, United

States

~

3+ Polio

3+ HepB

1+ Var

1+ MMR

4+ DTaP4+ PCV

Hib-FSHepB birth dose 2+ HepA

Rotavirus

4:3:1:3*:3:1:4

2+ Influenza

Source: CDC National Immunization Surveys; by birth cohort 2012-2018

Very Few U.S. Toddlers Have Received No Vaccines

0

0.2

0.4

0.6

0.8

1

1.2

1.4

2011 2012 2013 2014 2015 2016

We’ve got our challenges.

Coverage with some vaccines in some populations should be higher than it is.

0.0

20.0

40.0

60.0

80.0

100.0

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Pe

rce

nt

Vac

cin

ate

d (

%)

Year

≥1 Tdap

≥1 MenACWY

≥2 MenACWY

≥1 HPV

≥3 HPV

HPV UTD

Revised Definition ofAdequate Provider Data† Single Sample Frame Estimates§

ACIP recommendation2011–2015¶

ACIP recommendation2016–2018¶

Trends in Vaccination Coverage among Adolescents Aged 13-17 Years, NIS-Teen, United States, 2006-2018

≥ 70%

60% - 69%

50% - 59%

40% - 49%

30% - 39%HI

AK

DC

Range:78.1% (RI)

to32.6% (MS)

Estimated Up-to-Date HPV Vaccination Coverage among Adolescents, 2018

National Coverage = 51%

Estimated Vaccine Coverage among Adults aged ≥19 Years by Age Group and Risk Status, NHIS, 2010-2017

0

10

20

30

40

50

60

70

80

90

100

2010 2011 2012 2013 2014 2015 2016 2017

Per

cen

tage

Year

Influenza - age ≥19 yrs Pneumococcal - age 19-64 yrs, increased riskPneumococcal - age ≥65 yrs Tetanus-toxoid (Td or Tdap) - age ≥19 yrsHerpes zoster - age ≥60 yrs Influenza - age ≥19 yrs, high riskTdap - age ≥19 yrs

National Health Interview Survey

Disparities in vaccine coverage persist

Vaccination Coverage Estimates among Adolescents Aged 13-17 Years by MSA status, NIS-Teen, United States, 2018

*

*

MSA = Metropolitan statistical area

* Statistically different from adolescents living in MSA principal cities (p<0.05).

88.6 86.5

71.9

56.1

89.7 88.3

66.6

49.1

86.879.5

59.5

40.7

0.0

20.0

40.0

60.0

80.0

100.0

≥1 Tdap ≥1 MenACWY ≥1 HPV HPV UTD

Pe

rce

nt

Vac

cin

ate

d

Vaccine

MSA Principal City MSA Non-Principal City non-MSA

**

**

*

Estimated Influenza Vaccine Coverage among Adults aged ≥19 Years by Race/Ethnicity, NHIS, 2016-2017 Season

0 10 20 30 40 50 60

White

Black

Hispanic

Asian

Other

National Health Interview Survey

Measles is still a threat.

7

0

0

77

0

0

00

0

00

0

00

0

Measles Cases Reported by Month, 2019 (as of October 3)

https://www.cdc.gov/measles/cases-outbreaks.html

Measles has Increased 300% Globally in 2019Measles incidence for 12-month period

Top 10**

Country Cases Rate

Madagascar 92181 3702.86

Ukraine 85833 1931.5

India**** 41264 31.16

Philippines 32821 317.66

Nigeria 25044 134.65

Pakistan 11247 58.21

Yemen 10562 382.9

Brazil 9983 48.08

DR Congo 8971 113.94

Kazakhstan 8476 471.21

Other countries with high

incidence rates***

Country Cases Rate

Georgia 5024 1279.87

The Republic of

North

Macedonia

1369 657.79

Kyrgyzstan 2982 500.69

Israel 4011 489.63

Bosnia and

Herzegovina1150 327

• Notes: Based on data received 2019-07 and covering the period between 2018-06 and 2019-05 - Incidence: Number of cases / population* * 100,000 - * World population prospects, 2019 revision - ** Countries with the highest number of cases for the period - *** Countries with the highest incidence rates (excluding those already listed in the table above) ****WHO classifies all suspected measles cases reported from India as measles clinically compatible if a specimen was not collected as per the algorithm for classification of suspected measles in the WHO VPD Surveillance Standards. Thus numbers might be different between what WHO reports and what India reports.

Measles cases from countries with known discrepancies between case-based and aggregate surveillance, as reported by country

Country YearCases in Case-

basedCases in Aggregate Data Source for aggregate #s

DR Congo 2018 5597 67072 SITUATION EPIDEMIOLOGIQUE DE LA ROUGEOLE EN RDC, Week of 09/07/20192019 6138 118,647

Somalia 2018 131 9135Somali EPI/POL Weekly Update Week 26

2019 28 1967

Measles is still a threat,especially in communities with low vaccine

coverage.

Responding to dynamics shared by recent outbreaks

Pockets of low vaccination

Myths & misinformation

Vaccine access

Pockets of low vaccination

Close-knit, under-vaccinated communities a key vulnerability

Each community is unique, with distinct factors affecting vaccination

Isolation or insularity

Localized misinformation

Access issues

Distrust of public authorities

Myths and misinformation

Myths have always been part of the vaccine landscape

But rapid dissemination and sophistication of misinformation present new challenges

While its impact nationally is unclear, misinformation plays a clear role in under-vaccination in some local communities

Vaccine misinformation can be tailored for specific communities.

Vaccinate with Confidence i D ’ gic framework for strengthening vaccine

confidence and preventing outbreaks of vaccine preventable diseases in the United

States

Protect communitiesUse every tool available to find and protect communities at risk using tailored,

targeted approaches

Empower familiesEnsure parents are confident in decision to vaccinate by strengthening

provider-parent vaccine conversations

Stop mythsUse local partners and trusted messengers, establish new partnerships to

contain the spread of misinformation, and educate critical stakeholders about

vaccines 30

To protect communities from outbreaks, we have to find the communities that are most vulnerable first

New Investments and Activities

L v g D ’ 0 I iz i and Vaccines for Children cooperative agreement to support awardee efforts to find and respond to pockets of low vaccine coverage in their jurisdictions

Use immunization information system data and small-area analyses to pinpoint areas of low vaccination coverage and identify barriers to vaccination

Build immunization program capacity to effectively respond to outbreaks

Vaccinate with Confidence tagline

To ensure parents are confident in the decision to vaccinate, we need to equip health care professionals with resources to have effective vaccine conversations

Vaccinate with Confidence tagline

New Investments and Activities

• Support partners to help vaccine conversations start earlier with parents of very young infants and pregnant women

• Reduce hesitancy and improve v cci cc i ’ community health centers

• Develop provider toolkit to address p ’ v cci q i d i g outbreaks of vaccine-preventable diseases

We must ensure reliable information is not drowned out by misinformation, educate key stakeholders about vaccines, and engage trusted local messengers to provide accurate and reliable information about vaccines

New Investments and Activities

Work with social media companies to promote trustworthy vaccine information

Educate state policy makers on vaccine safety and effectiveness

Engage state and local health officials to advance effective local responses and community-based initiatives to misinformation and hesitancy

In the U.S., 32,100 cancers a year are caused by the types of HPV in our current 9-valent vaccine.

Estimated Number of Cancer Cases Attributable to HPV by Sex, Cancer Type, and HPV Type, United States, 2012-2016

www.cdc.gov/cancer/uscs/pdf/USCS-DataBrief-No10-August2019-h.pdf

HPV-Associated Cancer Rates by State, United States, 2012-2016

Rates per 100,000 populationhttps://www.cdc.gov/cancer/hpv/statistics/state/

13.4-16.0

12.0-13.3

11.4-11.7

8.5-11.3

HPV vaccine is safe and effective.

Initial Post-Licensure Monitoring of 9vHPV

▪ From December 2014 through December 2017, enhanced safety monitoring in VAERS found no unexpected or new safety concerns

– Approximately 29 million doses distributed in the United States during this time

• 7,244 total reports received in VAERS

• 186 (3%) serious reports

• Dizziness, syncope, headache were most frequently reported

– Safety profile consistent with data from 9vHPV pre-licensure clinical trials and similar to post-licensure safety data from 4vHPV monitoring in VAERS

▪ Between October 4, 2015-October 3, 2017, the Vaccine Safety Datalink conducted weekly sequential monitoring among persons aged 9-26 who received 9vHPV

– Approximately 900,000 doses administered and no concerning safety signals detected among pre-specified outcome monitored, which included:

• GBS, appendicitis, injection site reaction, anaphylaxis, stroke, syncope, venous thromboembolism, allergic reaction, chronic inflammatory demyelinating polyneuropathy, pancreatitis, seizures

Based on February 2018 ACIP presentation, https://www.cdc.gov/vaccines/acip/meetings/slides-2018-02.html

11.5%

18.5%

11.8%

9.5%

1.8%

5.3%

8.0%6.5%

0%

5%

10%

15%

20%

14–19 years 20–24 years 25–29 years 30–34 years

Pre

vale

nce

, %

2003–2006

2013–2016

aPR 0.14 (0.08-0.24)

aPR 0.29 (0.15-0.56)

aPR 0.61 (0.36-1.04)

aPR 0.73 (0.41-1.32)

86%*

71%*

Prevalence of Vaccine-type HPV (HPV 6,11,16,18) in Females, 2013-2016 Compared to Pre-vaccine Era

McClung et al. JAH 2019, in press *statistically significant declines

Although HPV vaccine coverage among adolescentshas increased, it’s still not where we need it to be.

Estimated Vaccination Coverage among Adolescents Aged 13-17 Years, National Immunization Survey-Teen, United States, 2006-2018

Walker et al., MMWR 2019. UTD: up-to-date. Revised definition of adequate provider data in 2013.

0

10

20

30

40

50

60

70

80

90

100

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Pe

rce

nt

Va

ccin

ate

d

Survey Year

≥1 MenACWY

≥1 HPV (females)≥1 HPV (males)

≥3 HPV (females)

≥3 HPV (males)

HPV UTD (females)HPV UTD (males)

≥1 Tdap

The provider recommendation for HPV vaccinationreally matters.

Now that Sophia is 11, she is due for vaccinations today to help protect her

from meningitis, HPV cancers, and pertussis.

HPV Vaccination Initiation Coverage by Provider Recommendation, National Immunization Survey-Teen, 2018

Received recommendation?

78%

22%

Yes

No

75%

25%

Vaccinated

Not vaccinated

47%

53%

Vaccinated

Not vaccinated

https://stacks.cdc.gov/view/cdc/80680

Parents who were missing a response, refused to respond, or responded, “don’t know” (n=1,448) were not included in the estimates.https://stacks.cdc.gov/view/cdc/80682

Range:90.7% (MA)

to59.5% (MS)

Percentage of Parents who Reported Receiving a Provider Recommendationfor HPV Vaccine, NIS-Teen 2018

How to Increase Vaccine Coverage

How to Increase Vaccine Coverage (1)

▪ Make a strong provider recommendation

▪ Recommend HPV vaccination the same way Tdap and MenACWY are recommended

▪ Make sure everyone in the office is working together to support your vaccination goals

▪ Assess coverage for every patient on the schedule and prompt clinicians to recommend vaccination

▪ Implement reminder/recall systems

How to Increase Vaccine Coverage (2)

▪ Use standing orders and allow immunization only visits

▪ Make the appointment for the next dose in the series before the patient leaves the office

▪ Assess vaccination coverage at the individual provider level and share feedback to providers

Providers need to be prepared to answerparents’ questions.

Reasons for Not Vaccinating Adolescents with HPV Vaccine, Unvaccinated Adolescents Aged 13-17 Years, NIS-Teen, United States, 2018

Parents of Girls Parents of Boys

Safety concerns/side effects

30% Safety concerns/side effects

22%

Not needed/not necessary

16% Not needed/not necessary

16%

Not sexually active 12% Not recommended 11%

Not recommended 7% Lack of knowledge 8%

Lack of knowledge 4% Not sexually active 7%

Answering parents’ questionshttps://www.cdc.gov/hpv/hcp/answering-questions.html

Frequently asked questions about HPV vaccine safetyhttps://www.cdc.gov/vaccinesafety/vaccines/hpv/hpv-safety-faqs.html

Influenza is a vaccine-preventable disease.

Influenza Vaccine Effectiveness Against Pediatric Deaths, 2010-2014

▪ From July 2010 through June 2014, 358 laboratory-confirmed influenza-associated pediatric deaths were reported among children 6 months-17 years of age

– Vaccination status was determined for 291 deaths

▪ For children overall

– 75 (26%) received vaccine before illness onset

– In comparison cohorts, average vaccination coverage was 48%

– VE against death was 65%

▪ For children with high-risk conditions (n=153)

– 47 (31%) were vaccinated, for a VE against death of 51%

Flannery et al, Pediatrics 2017

It’s a big job; all of us will need to work on it,

together.

Public Health’s Role in Immunization

Prevention of disease

Outbreak Detection and Response

Safe and Effective Immunization

Programs

Manage SupplyInform Parental

Vaccine Decisions

Ensure Vaccine Safety

Monitor impact and strengthen evidence

base

Monitor impact and

strengthen evidence base

Parents of Young Children: Three Most Trusted Sources of Vaccine Information

2018(N = 2,506)

Percent

1 Doctor or HCP 93%

2 Scientific or medical journal 41%

3 Family members 38%

4 Prenatal care provider 36%

5 Internet or social media 18%

6 Friends 10%

7 Books 9%

8 Magazines, newspapers, radio, TV 4%

Source: CDC National Poll of Parents 2018 (unpublished data)

33

Wrapping Up

▪ Remarkable ongoing success in childhood immunization, with broad support and high coverage

▪ Current outbreaks of measles in close-knit communities require collaboration between public health and health care providers to address

▪ Room for improvement in some areas:

– HPV vaccination of pre-teens

– Adult immunization

– Influenza vaccination for all ages

▪ We know what works – the challenge is

implementation

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank you

www.cdc.gov/vaccines