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Healthy People 2010: Immunization and Infectious Diseases
Lead Agency: Centers for Disease Control and Prevention
Contents
Overview Healthy People 2010-Summary of Objectives
Healthy People 2010 Objectives
Related Objectives From Other Focus Areas
Prevent disease, disability, and death from infectious diseases, including vaccine-preventable diseases. Infectious diseases remain major causes of illness, disability, and death. Moreover, new infectious agents and diseases are being detected, and some diseases considered under control have reemerged in recent years. In addition, antimicrobial resistance is evolving rapidly in a variety of hospital- and community-acquired infections. These trends suggest that many challenges still exist in the prevention and control of infectious diseases.
Issues The direct and indirect costs of infectious diseases are significant. Every hospital-acquired infection adds an average of $2,100 to a hospital bill. Bloodstream infections result in an average of $3,517 in additional hospital charges per infected patient because the patient stay averages an additional 7 days. A typical case of Lyme disease diagnosed in the early stages incurs about $174 in direct medical treatment costs. Delayed diagnosis and treatment, however, can result in complications that cost from $2,228 to $6,724 per patient in direct medical costs in the first year alone.1 Infectious diseases also must be considered in a global context. Increases in international travel, importation of foods, inappropriate use of antibiotics on humans and animals, and environmental changes multiply the potential for worldwide epidemics of all types of infectious diseases. International cooperation and collaboration on disease surveillance, response, research, and training are essential to prevent or control these epidemics. Actions taken to improve health in one country affect the health of people worldwide. Vaccines. Vaccines are biological substances that interact with the person's immune system to produce an immune response identical to that produced by the natural infection. Vaccines can prevent the debilitating and, in some cases, fatal effects of infectious diseases. Vaccines help to eliminate the illness and disability of polio,2 measles, and rubella.3 However, the organisms that cause these diseases have not disappeared. Rather, they have receded and will reemerge if the vaccination coverage drops. The serious health burden of vaccine-preventable diseases (VPDs) is evident from the measles resurgence of 1989 to 1991, resulting in more than 55,000 cases, 11,000 hospitalizations, 120 deaths, and $100 million in direct medical care costs.4, 5, 6, 7 Vaccines protect more than the vaccinated individual. They also protect society. When vaccination levels in a community are high, the few who cannot be vaccinated-such as young children and persons with contraindications to vaccination-often are indirectly protected because of group immunity (in other words, they live among vaccinated persons who may offer protection from exposure to disease). Vaccines provide significant cost benefits. Three childhood vaccines-diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP); measles, mumps, and rubella vaccine (MMR); and Haemophilus influenzae type b (Hib) vaccine-result in substantial direct medical savings for each dollar spent to vaccinate children against these diseases. Varicella vaccine saves roughly 90 cents in direct medical costs for every dollar invested. Consideration of indirect savings-prevention of work loss by parents to care for ill children, prevention of death and therefore lost earnings from disability-shows that vaccines routinely recommended for children are highly cost saving. Savings range from $24 for every dollar spent on DTaP to $2 for the more recently approved Hib vaccine.8
Trends
 In 1998, overall vaccination coverage for children aged 19 to 35 months was at record-high levels.10 Antigen-specific rates have shown striking progress since 1992.11 For example, coverage for three or more doses of polio vaccine increased from 72 percent to 91 percent, and coverage for three or more doses of Hib vaccine increased from 28 percent to 93 percent. Significant achievements also were made among racial and ethnic groups in that most of the 1996 goals for the Childhood Immunization Initiative were met for individual vaccines.12 Since 1989, vaccination requirements have been expanded for schools and day care settings.11 As of the 1998-99 school year, all States required vaccination against diphtheria, measles, and polio. Similarly, all States and the District of Columbia now require vaccination for day care.13 In 1996, a vaccine against hepatitis A virus (HAV) was licensed that has the potential to reduce the health burden of this disease as well. The vaccine is now recommended primarily for high-risk groups. To decrease hepatitis A virus transmission, universal vaccination was recommended in 1999 for children who lived in States where the rate of new cases was greater than two times the national average.14 Financing for childhood vaccinations has improved significantly as a result of two initiatives-Vaccines for Children and the Children's Health Insurance Program that cover children on Medicaid, uninsured children, and Native American and Alaskan Native children. Underinsured children who receive vaccinations at Federal and rural health clinics also are covered. Because they promote free vaccines for children, these programs eliminate vaccine cost as a barrier to childhood vaccination. Also, the Public Health Service Act, Section 317 immunization grant program and State funds provide free vaccines for children not covered by other programs. Adult vaccination rates continued to increase over the decade. Influenza vaccine coverage rates were up from 33 percent in 1989 to 63 percent in 1997, and pneumococcal vaccine coverage rates were up from 15 percent to 43 percent. Despite these increases, coverage rates for certain racial and ethnic groups remain substantially below the general population.15 Invasive diseases invade the bloodstream and cause distant infection. The most common types of invasive disease caused by Haemophilyus influenzae type b (Hib) are meningitis, epiglottitis, pneumonia, certain types of arthritis, and cellulitis. Conjugate vaccines-licensed in 1990 for use beginning at age 2 months-are highly effective in protecting against Hib meningitis and other invasive diseases caused by Hib. These vaccines also interrupt spread of the disease-causing organism by affecting the organism's nasopharyngeal colonization. New cases of Hib meningitis declined by 96 percent from 1987 to 1995.16 During that period, bacterial meningitis caused by one of the five leading agents (Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, group B Streptococcus [GBS], and Listeria monocytogenes) fell by 55 percent. Bacterial meningitis was traditionally a disease of childhood, infecting children with a median age of 15 months in 1986.17 Following the dramatic reduction in Hib meningitis, which primarily occurs among children under age 2 years, the median age of persons with the disease shifted to 25 years in 1995.17 The success of conjugate vaccines against Hib disease has stimulated efforts to develop conjugate vaccines for other pathogens, including Streptococcus pneumoniae, Neisseria meningitidis, and GBS. Conjugate vaccines against these three agents are being tested in clinical trials. The success of bacterial meningitis vaccines suggests comparable results may be achieved for other causes of meningitis, sepsis, and pneumonia as their conjugate vaccines become used more routinely in target populations.
Disparities Efforts need to be intensified, particularly to increase vaccination coverage for children living in poverty. Substantial numbers of undervaccinated children remain in some areas, particularly the large urban areas with traditionally underserved populations, creating great concern because of the potential for outbreaks of disease. In addition to very young children, many adults are at increased risk for VPDs. Vaccination against pneumococcal infections and influenza among persons aged 65 years and over has increased slightly for African Americans and Hispanics. The coverage in these groups, however, remains substantially below the general population. For example, influenza vaccination rates for whites were 66 percent in 1997, while for African Americans and Hispanics, rates were only 45 and 53 percent, respectively. In September 1997, the Department of Health and Human Services approved a plan to improve adult vaccination rates and reduce disparities among racial and ethnic groups.19 The elimination of disparities, however, may require further interventions in particular geographic, cultural, or racial and ethnic populations.
Opportunities Priority issues include antimicrobial resistance, foodborne and waterborne diseases, vector-borne and zoonotic diseases, diseases transmitted through transfusion of blood or blood products, and vaccine development and use. Some of these diseases and pathogens were unknown 20 years ago. Others are reemergent problems once thought under control. At-risk populations include persons with impaired host defenses; pregnant women and newborns; travelers, immigrants, and refugees; older adults; or other persons identified by the Advisory Committee on Immunization Practices (ACIP). The major strategies to protect people from VPDs are the following:20
In the United States, most VPDs occur among adults. Pneumococcal disease and influenza account for more than 30,000 deaths annually, most of which occur in elderly persons. Studies have consistently shown that focusing efforts to improve coverage on health care providers, as well as health care systems, is the most effective means of raising vaccine coverage in adults. For example, all health care providers should assess routinely the vaccination status of their patients. Likewise, health plans should develop mechanisms for assessing the vaccination status of their participants. Also, nursing home facilities and hospitals should ensure that policies exist to promote vaccination. Since no vaccine is completely safe, vaccine safety research and monitoring are necessary to identify and minimize vaccine-related injuries. As programs continue to reduce the new cases of VPDs, concerns about vaccine adverse events have emerged, posing a threat to public acceptance of vaccines. Knowing the safety profile of vaccines is essential to assess accurately the risks and benefits, to formulate appropriate vaccine recommendations, and to address public concerns. Interim Progress Toward Year 2000 Objectives Significant progress has been made in reaching the Healthy People 2000 objectives. Reductions in indigenous cases of VPDs have been dramatic. For example, measles was reduced from a 1988 baseline of 3,396 indigenous cases to a total of only 100 in 1998. Substantial progress also has been made in reducing hepatitis B virus (HBV) transmission. The vaccine against hepatitis A provides the opportunity to reduce the burden of this disease. Achieving the year 2000 objective to reduce new cases of bacterial meningitis was entirely due to the introduction of Hib conjugate vaccines for infants.24 In 1998, individual coverage levels for children aged 19 to 35 months were at record high levels. For example, individual coverage levels for three or more doses of polio, three or more doses of diphtheria/tetanus/acellular pertussis, one or more doses of measles/mumps/rubella, and three or more does of Hib vaccines were each at or above 91 percent. Progress has also been made in expanding immunization requirements for schools and day care settings. Data for viral hepatitis indicate that targets for hepatitis B and C were met in the early 1990s. Note:Unless otherwise noted, data are from Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998-99. Healthy People 2010-Summary of Objectives Immunization and Infectious Diseases Goal: Prevent disease, disability, and death from infectious diseases, including vaccine-preventable diseases.
Healthy People 2010 Objectives Diseases Preventable Through Universal Vaccination 14-1. Reduce or eliminate indigenous cases of vaccine-preventable disease. Target and baseline:
Target setting method: Total elimination for congenital rubella syndrome, diphtheria, Haemophilus influenzae type b, measles, mumps, polio, rubella, and tetanus; 41 percent improvement for pertussis; 99 percent improvement for hepatitis B; and 99 percent improvement for varicella. Highly effective vaccines are used routinely in childhood for prevention of measles, mumps, rubella, varicella, diphtheria, tetanus, pertussis, polio, hepatitis B, and Hib invasive disease.26 Vaccinations for these diseases have reduced reported cases of most VPDs common in childhood to record-low levels.10, 25, 27 Measles transmission probably was interrupted multiple times in the United States since 1993.28, 29, 30 With a high level of coverage of two doses of measles, mumps, and rubella vaccine, interruption of the spread of both rubella and mumps is feasible.31, 32 Recent outbreaks of rubella and a number of cases of congenital rubella syndrome, however, highlight the importance of ensuring rubella immunity particularly in women of child-bearing age and foreign-born adults.33 Polio has been eliminated in the United States due to high vaccination coverage. Although polio is expected to be eradicated globally, surveillance for cases of the disease will continue. Because of widespread vaccination, reported cases of diphtheria are near zero.34, 35 Tetanus toxoid is highly effective, but with the absence of group immunity, all persons must be vaccinated to achieve the goal of zero cases.36 Pertussis among children will be reduced by increasing vaccination coverage, but the disease will continue to occur because the organism circulates among older age groups, and the vaccine is not 100 percent effective.37, 38 Hepatitis B virus (HBV) infection will be reduced greatly as the age groups covered by universal infant and adolescent vaccination efforts enter young adulthood, a periodwhen the risk of HBV infection increases. Conjugate vaccines for prevention of Haemophilus influenzae type b are highly effective and have led to near elimination of invasive Hib disease.16, 39 Further reductions in new cases are anticipated as Hib vaccine coverage increases. The licensure of new vaccines against common diseases that are not reportable diseases, such as varicella, has created new challenges for surveillance and evaluation. Without national reporting, documenting the impact of national and State vaccination programs and measuring progress for reducing indigenous cases of disease are difficult.40 However, with an increase in vaccination coverage and a decline in the number of new cases, varicella is expected to become a reportable condition. 14-2. Reduce chronic hepatitis B virus infections in infants and young children (perinatal infections).
Target: 400 infections. Each year, 16,000 to 18,000 children in the United States are born to mothers infected with HBV.41 Without prevention programs, about 8,000 of these infants would become infected with HBV. Ninety-five percent of the infections, however, are preventable through appropriate maternal screening and infant care.42 Screening pregnant women during an early prenatal visit is essential to identify those who are infected. Women at high risk should be retested late in pregnancy. In 1997, 14 States had laws or regulations to ensure such screening. To be maximally effective, steps to prevent transmission of HBV to infants born to mothers who are infected must begin as soon as the child is born. Such infants should receive a first dose of hepatitis B vaccine within 12 hours of birth, along with hepatitis B immune globulin (HBIG), and two more doses of vaccine by age 6 months. Children need to be tested between the ages of 12 and 15 months to ensure that they are not infected and have developed immunity to the virus. 14-3. Reduce hepatitis B. Target and baseline:
Target setting method: Better than the best for 14-3a, 14-3b, and 14-3c; 75 percent improvement for 14-3d, 14-3f, and 14-3g; 92 percent improvement for 14-3e.
To reduce HBV transmission in the United States by 2010, vaccination programs must be targeted to adolescents and adults in high-risk groups. The primary means of achieving high levels of vaccination coverage in groups with behavioral risk factors for HBV infection is to identify settings where these individuals can be vaccinated. Such sites include clinics that treat sexually transmitted diseases, correctional facilities (juvenile detention facilities, prisons, jails), drug treatment clinics, and community-based HIV prevention sites. The primary means of achieving high levels of vaccine coverage among household and sex contacts of the estimated 1.25 million persons in the United States with chronic HBV infection are programs that offer followup for all HbsAg-positive persons reported to State and local health departments. Routine infant vaccination eventually will produce a highly immune population sufficient to eliminate HBV transmission in the United States. However, high rates of acute hepatitis B continue to occur, with an estimated 65,000 cases in 1996. Most cases occur in young adult risk groups, including persons with a history of multiple sex partners, men who have sex with men, injection drug users, incarcerated persons, and household and sex contacts of persons with HBV infection. Investigation of reported cases of acute hepatitis B indicates that as many as 70 percent of these individuals previously had been seen in settings such as drug treatment clinics, correctional facilities, or clinics for the treatment of STD where they could have received vaccine. 14-4. Reduce bacterial meningitis in young children.
Target: 8.6 new cases per 100,000 children aged 1 through 23 months.
Children aged 1 month to 2 years have higher rates of meningitis than older children. New vaccines for pneumococcal disease, including pneumococcal meningitis, may help protect young children. Meningococcal conjugate vaccines are in clinical trials and may become available for widespread use before 2010, although it is not yet known whether they will target young children. Pneumococcal conjugate vaccines, modeled after the successful construction of Hib conjugate vaccines, are also in clinical trials. Before 2010, licensure and widespread use of these new products are expected. 14-5. Reduce invasive pneumococcal infections. Target and baseline:
Target setting method: Better than the best.
The number of invasive penicillin-resistant pneumococcal infections can be reduced by lowering the proportion of invasive pneumococcal infections due to drug-resistant strains or by decreasing invasive pneumococcal infections in general. The objectives for specific age groups address the key age groups at risk for invasive pneumococcal infections. Among children under age 5 years, promoting judicious antibiotic use may reverse the current trends toward increasing proportions of infections being caused by drug-resistant strains. For adults aged 65 years and older, licensure and widespread use of pneumococcal conjugate vaccines by 2010 could reduce dramatically all invasive pneumococcal infections, and judicious antibiotic use may have some impact on the proportion of pneumococcal infections caused by drug-resistant strains. In this age group, a much greater impact potentially is achievable through improved use of licensed 23-valent pneumococcal polysaccharide vaccine for the prevention of invasive pneumococcal disease. Increasing the use of this vaccine for elderly persons could have a beneficial impact on the rate of drug-resistant invasive pneumococcal infections. Diseases Preventable Through Targeted Vaccination 14-6. Reduce hepatitis A.
Target: 4.5 new cases per 100,000 population.
The health status objectives for HAV will not be achieved until a vaccination strategy is implemented that produces high levels of immunity in children. Children have the highest rates of hepatitis A and are a primary source for new infections in the community. In 1999, the Advisory Committee on Immunization Practices (ACIP) recommended routine hepatitis A vaccination for children living in States with consistently elevated rates of hepatitis A as the approach most likely to prevent and control transmission of HAV.14 Hepatitis A vaccine is included in the Vaccines for Children Program. Incorporation of hepatitis A vaccine into the routine childhood vaccination schedule would facilitate implementation of these recommendations, but data are needed to determine the appropriate dose and timing of vaccination in the first or second year of life. Implementation of the recommendations also would be enhanced by the development of vaccines that combine HAV antigen with other antigens. Although routine immunization of children is the approach most likely to decrease significantly the overall rates of hepatitis A in a community, it may take some time before the impact of implementing these programs is measurable. In the interim, persons in groups at high risk of HAV infection should be vaccinated routinely. These groups include:
Target: 1.0 new cases per 100,000 population.
The polysaccharide meningococcal vaccine currently available in the United States is recommended for certain high-risk groups (people with asplenia), for laboratory personnel routinely exposed to Neisseria meningitidis, and for travelers to regions where meningococcal disease is hyperendemic or epidemic (the African Ameningitis belt). Routine vaccination of civilians is not recommended because of its relative ineffectiveness in children under age 2 years (among whom risk of endemic disease is highest) and its relatively short duration of protection. The vaccine is useful for controlling serogroup C meningococcal epidemics; these account, however, for less than 5 percent of the cases of meningococcal disease that occur each year in the United States. The vaccine provides no protection against serogroup B meningococci, which account for approximately one-third of the disease overall in the United States. New meningococcal conjugate vaccines against serogroups C and Y, which account for two-thirds of current disease, are now undergoing clinical trials. Soon they should be available for incorporation into routine childhood immunization as well as for vaccination of high-risk groups, possibly including college students. Similar to Hib conjugate vaccines, new meningococcal conjugate vaccines are expected to be effective in children. Development and licensing of new serogroup B meningococcal vaccines will also help reduce meningococcal disease. 14-8. Reduce Lyme disease.
Target: 9.7 new cases per 100,000 population in endemic States.
In 1991 a standardized case definition for Lyme disease was adopted by the Council of State and Territorial Epidemiologists. Since then, the number of reported cases of Lyme disease has increased from 8,257 in 1993 to 16,455 in 1996 because of increased surveillance as well as a true increase in new cases. From 1992 through 1996, 92 percent of cases were reported from 10 endemic States. New initiatives to prevent Lyme disease include the implementation of community-based prevention programs, host-targeted acaricides to reduce the numbers of vector ticks, and appropriate use of Lyme disease vaccine. Infectious Diseases and Emerging Antimicrobial Resistance 14-9. Reduce hepatitis C.
Target: 1 new case per 100,000 population.
Hepatitis C virus (HCV) is the most common chronic bloodborne viral infection in the United States.43 This virus is usually transmitted through large or repeated percutaneous exposures to blood-for example, through sharing of equipment between injection drug users. HCV infects persons of all ages, but most new cases are among young adults aged 20 to 39 years. The highest proportion of new cases is among whites, but the highest rates of new cases are among nonwhite racial and ethnic groups. 14-10. (Developmental) Increase the proportion of persons with chronic hepatitis C infection identified by State and local health departments. Potential data sources: State health department databases of persons with HCV infection; National Health and Nutrition Examination Survey (NHANES), CDC, NCHS. An estimated 4 million persons in the United States are infected chronically with HCV.Although the annual number of newly acquired HCV infections has declined from an estimated 180,000 in the mid-1980s to an estimated 28,000 in 1995, this reservoir of chronically infected persons can transmit the virus to others, and all of them are at risk for the severe consequences of chronic liver disease. Because of the large number of people with chronic HCV infection, identification of these persons must be a major focus of a comprehensive prevention strategy. Identification of HCV-infected persons allows (1) counseling to prevent further HCV transmission, (2) vaccination against HAV and HBV to prevent additional liver damage, (3) evaluation for chronic liver disease, (4) possible antiviral therapy, and (5) counseling to avoid potential hepatotoxins, such as alcohol, that may increase the severity of HCV-related liver disease. 14-11. Reduce tuberculosis.
Target: 1.0 new case per 100,000 population.
The 1989 Strategic Plan for the Elimination of TB in the United States44 set a tuberculosis elimination goal of reducing TB to 1 per million by 2010, with an interim goal of 3.5 cases per 100,000 population by 2000. However, in the mid-1980s the trend toward TB elimination was reversed, and drug-resistant strains emerged that were even more deadly. TB cases increased by 20 percent between 1985 and 1992. Renewed efforts to combat the resurgence included improving laboratories, strengthening surveillance and expanding directly observed therapy, and expediting investigation of close contacts of TB patients. From 1993 through 1998, new cases of TB again declined, although the resurgence and related outbreaks set back TB elimination efforts by about a decade. This effort depends on significant effort and cooperation between public and private health care providers and agencies at the Federal, State, and local levels. 14-12. Increase the proportion of all tuberculosis patients who complete curative therapy within 12 months.
Target: 90 percent of patients.
Data for socioeconomic status currently are not collected. The highest priority for TB control is to ensure that persons with the disease complete curative therapy. If treatment is not continued for a sufficient length of time, such persons often become ill and contagious again. Completion of therapy is essential to prevent transmission of the disease as well as to prevent outbreaks and the development and spread of drug-resistant TB. Current therapy guidelines recommend that patients with drug-susceptible TB should complete a successful regimen within 12 months.45 Multidrug-resistant TB presents difficult treatment problems, often requiring consultation with a TB specialist and longer treatment regimens. The measurement of completion of therapy is a long-accepted indicator of the effectiveness of community TB control efforts. Health departments traditionally have reported completion-of-therapy results to CDC and used this information locally and statewide as an evaluation measure. 14-13. Increase the proportion of contacts and other high-risk persons with latent tuberculosis infection who complete a course of treatment.
Target: 85 percent. Data for population groups currently are not collected. Treatment for latent TB infection substantially reduces the risk that TB infection will progress to disease. Certain groups are at very high risk of developing TB disease once infected. Identifiable population groups at high risk for TB vary in time and geographic area depending on unique and changing TB-related demographics.46 14-14. Reduce the average time for a laboratory to confirm and report tuberculosis cases.
Target: 2 days for 75 percent of cases. Commercially available nucleic acid amplification tests are capable of detecting Mycobacterium tuberculosis in a specimen within 48 hours of receipt. Concerns regarding sensitivity, cost, quality control, and special expertise requirements prevent widespread use of such tests. Upgrading TB laboratory capabilities and facilities, improving training in state-of-the-art mycobacteriology, and evaluating proficiency should better enable State public health laboratories to apply these new rapid tests to the diagnosis of TB. 14-15. (Developmental) Increase the proportion of international travelers who receive recommended preventive services when traveling in areas of risk for select infectious diseases: hepatitis A, malaria, typhoid. Potential data source: Abstract of International Travel To and From the United States, U.S. Department of Commerce. The number of international travelers from the United States has increased an average of 3 percent a year for the past decade. The three diseases highlighted in this objective-hepatitis A, malaria, and typhoid-account for a large proportion of illness and disability for international travelers. Before embarking, some travelers go to a travel clinic, some visit primary care providers, and some receive no pretravel care. An appropriate prescription of antimalarial prophylaxis medications constitutes recommended preventive services for this disease. Risk areas can be identified by referencing the malaria section in the most recent edition of Health Information for International Travel. 14-16. Reduce invasive early onset group B streptococcal disease.
Target: 0.5 new cases per 1,000 live births.
The number of new cases of early onset group B streptococcal (GBS) disease in 1996 reflected a substantial decline from earlier years, before intervention became common practice. GBS causes bloodstream infections and meningitis in babies. Additional prevention is possible, since occurrence of the disease is more likely to reflect ineffective prevention efforts than antibiotic failures. In certain areas, rates approximating 0.5 per 1,000 births already have been achieved. Although these data may represent the background rate of nonpreventable cases, most geographic areas should be able to achieve the same low rates. The racial disparity in rates will be eliminated with more aggressive use of prevention protocols. African Americans have consistently had higher rates of GBS diseases than other races. Implementation of GBS prevention policies is expected to eliminate the disparity. Thus, the target of 0.5 cases per 1,000 births is one that can be obtained in all geographic areas and all racial and ethnic groups. By the year 2010, reductions in early-onset disease might be the result of both improved use of intrapartum antibiotic prophylaxis and implementation of GBS conjugate vaccines currently in clinical trials. 14-17. Reduce hospitalizations caused by peptic ulcer disease in the United States.
Target: 46 hospitalizations per 100,000 population.
Peptic ulcer disease affects up to 25 million persons in the United States and causes up to 6,500 deaths each year. Until recently, peptic ulcers were thought to be caused by stress, spicy foods, and excess stomach acid. Most patients were treated with antacids or acid-reducing medications, and recurrences were the rule after therapy was discontinued. The discovery in the 1980s that a bacterial organism, Helicobacter pylori (H. pylori), causes up to 90 percent of peptic ulcers has changed the way ulcers are evaluated and managed.47, 48 Now appropriate antibiotic regimens successfully eradicate the infection and prevent recurrence and complications such as bleeding or perforation. Despite extensive scientific data linking peptic ulcer disease to H. pylori, studies indicate that many health care providers and consumers are unaware of the relationship, and many persons with ulcers do not receive appropriate therapy.49, 50 A campaign to educate health care providers and consumers about H. pylori and its link to peptic ulcer disease was initiated in 1997. The CDC and Partnership H. pylori Educational Campaign includes partners from academic institutions, government agencies, and industry.51 The increased awareness of the link between H. pylori and ulcers among health care providers and consumers is expected to lead to the increased use of appropriate antibiotics. This improved treatment, if available to those who need it, should decrease hospitalization rates-an indicator for severe illness and disability-due to peptic ulcer disease and its complications. 14-18. Reduce the number of courses of antibiotics for ear infections for young children.
Target: 88 antibiotic courses per 100 children under age 5 years.
Data for socioeconomic status currently are not collected. Antibiotic courses for otitis media, commonly called ear infection, can be reduced through two methods. A portion of otitis media cases-otitis media with effusion, rather than acute otitis media-do not require antimicrobial treatment. A national campaign for judicious antibiotic use aims to reduce inappropriate antibiotic treatment for this portion of otitis media.52 The leading cause of otitis media is pneumococcus. Preventing pneumococcal otitis media is expected to be possible following licensure of pneumococcal conjugate vaccines. (See Focus Area 28. Vision and Hearing.) 14-19. Reduce the number of courses of antibiotics prescribed for the sole diagnosis of the common cold.
Target: 1,268 antibiotic courses per 100,000 population.
The common cold does not require antimicrobial therapy. Inappropriate therapy for the common cold can be reduced by 50 percent by promoting judicious antimicrobial use, provided that care givers and patients accept that antibiotics are ineffective in treating colds. Effective programs for the judicious use of antibiotics could help reduce the prescription of antibiotics for the common cold. 14-20. Reduce hospital-acquired infections in intensive care unit patients.
Target setting method: 10 percent improvement. (Better than the best will be used when data are available.) Data for population groups currently are not collected. Hospital-acquired infections are a leading cause of illness and death in the United States. Each year, 36 million patients are admitted to U.S. hospitals. Annually, more than 500,000 of the nearly 2 million patients stricken with a hospital-acquired infection are intensive care patients. Of the total, nearly 90,000 die. The annual cost of hospital-acquired infections is approximately $4.5 billion a year. In the last 20 years, the rate of hospital-acquired infections has increased 36 percent. The rate of hospital-acquired infections has increased largely because hospital patients of the late 1990s on average were older and sicker than those of 20 years earlier and thus more susceptible to infection, and also because medical advances that can save or prolong lives may carry risks for infections. Because both trends are expected to continue, only a modest reduction in the number of new cases of infections can be expected; however, a small reduction will save thousands of lives. 14-21. Reduce antimicrobial use among intensive care unit patients.
Target: 120 daily doses per 1,000 patient days. Hospital-acquired infections caused by antimicrobial-resistant pathogens can be virtually untreatable. Further, antimicrobial resistance that develops in the hospital can spread into the community and has the potential to cause a public health disaster. Excessive or inappropriate use of antimicrobials or both, which occur most frequently in intensive care units (ICUs), is the major cause of antimicrobial resistance. Research indicates that antibiotics are being used more often than hospital prescription guidelines recommend. For example, one study in the late 1990s indicated that as much as 60 percent of the hospital prescriptions for vancomycin are not in accordance with the guidelines. Decreasing the use of antimicrobials, especially in intensive care units, is the critical step in reducing the public threat of antimicrobial resistance. Studies have shown that interventions in individual hospitals have achieved reductions of 20 percent or more in antimicrobial use. Vaccination Coverage and Strategies 14-22. Achieve and maintain effective vaccination coverage levels for universally recommended vaccines among young children. Target and baseline:
Target setting method: Consistent with the Childhood Immunization Initiative.
Vaccination coverage levels of 90 percent are, in general, sufficient to prevent circulation of viruses and bacteria causing vaccine-preventable diseases.53, 54 Maintenance of high vaccination coverage levels in early childhood is the best way to prevent the spread of VPDs in childhood and to provide the foundation for controlling VPDs among adults. Diseases that affect humans only may eventually be eradicated or at least eliminated through high vaccination coverage levels.55 These diseases include polio and measles in the near future and possibly hepatitis B later on. Although polio is expected to be eradicated by the year 2000, vaccine coverage levels will continue to be assessed until vaccination is no longer recommended. The measles epidemic of 1989-91 demonstrated that achievement of high coverage levels at the time of school entry was insufficient to control VPD outbreaks. Although coverage levels are currently the highest ever recorded, the United States must continue to assure that each new cohort of children is fully vaccinated with all required vaccine doses; as of November 1, 1999, 16 to 20 vaccine doses are required through age 16 years with 12 to 16 doses by age 2 years. Any new universally recommended vaccine should be at a 90 percent coverage level within 5 years of the recommendation. Although national coverage levels may exceed 90 percent, variation in the level of coverage among smaller areas may include subgroups of the population at substantially lower levels of protection. These subgroups or pockets of undervaccinated persons make the population vulnerable to major outbreaks of VPDs. Monitoring of coverage at smaller geographic levels within the United States helps ensure that these potential pockets of children are identified to target interventions and reduce the risk of future disease outbreaks. In addition, each State and major urban area should aim to achieve 90 percent coverage to ensure uniformly high vaccination coverage. 14-23. Maintain vaccination coverage levels for children in licensed day care facilities and children in kindergarten through the first grade. Target and baseline:
Target setting method: Consistent with year 2000 target. (Better than the best will be used when data are available.) Data for population groups currently are not collected. Uniformly high coverage levels are required to prevent circulation of the viruses and bacteria that cause VPDs. The target level was set to be consistent with the Healthy People 2000 objective because the achievement of that objective has been successful at preventing disease spread, and this objective seeks to maintain the high coverage achieved in these settings. Entry requirements for school and day care are one of the most effective interventions the States have at their disposal to ensure that children are appropriately vaccinated. The impact of entry requirements for school and day care has been profound-more than 95 percent of children are vaccinated. Several studies support the role of entry requirements in increasing vaccination rates and decreasing the rate of new cases of measles. Strict enforcement of school vaccination requirements has been shown to play a determining role in lowering new cases of measles.56 14-24. Increase the proportion of young children who receive all vaccines that have been recommended for universal administration for at least 5 years.
Target: 80 percent of children aged 19 through 35 months.
Determining whether the population is protected against a VPD is best evaluated by examining the immunization coverage of individual vaccines (see objective 14-22). It is also important to assure that the health care system fully vaccinates individual children, providing vaccines that have been universally recommended for at least 5 years and that are currently recommended. Changes in the immunization schedule will occur as new vaccines are added to the list of recommended vaccines and as vaccines for eradicated diseases are removed from the list.57 For example, polio virus vaccine is not expected to be recommended by the year 2010. Although monitoring the proportion of children who have received the combination of four DTaP, three polio, and one MMR will continue for historical comparison, attention should be focused on the combination of all universally recommended vaccines. 14-25. Increase the proportion of providers who have measured the vaccination coverage levels among children in their practice population within the past 2 years. Target and baseline:
Target setting method: 36 percent improvement for public health providers; 1,400 percent improvement for private providers.
In 1997, 66 percent of public health department providers assessed their vaccination levels.58 State immunization programs are collaborating with private providers to extend provider-based assessments to the private sector. With the increasing role of managed care and Health Plan and Employer Data and Information Set (HEDIS) measures, private providers should have additional occasions to examine their coverage levels. Most providers (public and private) overestimate the vaccination coverage level they are achieving with their clients.59 Assessment of practice-based coverage levels and feedback of those data to the providers have been an effective strategy for increasing vaccination of children served by a given practice.60, 61 Managed care organizations have begun reporting vaccination coverage levels using the HEDIS criteria as a way of evaluating quality of care.62 Practice-based assessment also has been recommended by the Advisory Committee on Immunization Practices,63 the National Vaccine Advisory Committee, the American Academy of Pediatrics, and the American Academy of Family Physicians.64 The Clinic Assessment Software Application provides a mechanism for assessing levels of vaccination coverage as well as for tracking patients; the system reminds patients of upcoming vaccinations and sends notices for children who are overdue. 14-26. Increase the proportion of children who participate in fully operational population-based immunization registries.
Target: 95 percent of children under age 6 years. Data for population groups currently are not collected. A fully operational population-based registry includes capabilities to (1) protect confidential information, (2) enroll all children at the State or community level automatically at birth, (3) give providers access to complete vaccination history, (4) recommend needed vaccinations, (5) notify children who are due and overdue for vaccinations, (6) assess practice and geographic-level coverage, and (7) produce authorized immunization records. Registries may provide other important functions such as automatic reporting of adverse events. Registries may serve other purposes as well, including VPD surveillance, vaccine efficacy monitoring, and vaccine inventory management. Population-based immunization registries will be a cornerstone of the Nation's immunization system by 2010. Responsibility for registry development rests with State and local communities, with assistance from Federal agencies and private partners. Registries facilitate the timely vaccination of children by ensuring that the child's complete vaccination history is available to the health care provider. Registries are valuable given the mobile nature of today's population and that many persons do not see the same provider consistently. Registries also can be used to monitor the vaccination status of populations that are low income, uninsured, and at greater risk for incomplete vaccination. Few population-based immunization registries existed at the State or community level before 1992, and limited data are available regarding their implementation. A 1999 CDC survey shows immunization registries are being developed in all States.65 Additional efforts are underway to establish registry links between private providers and immunization partners such as managed care organizations and WIC programs. Issues such as privacy, confidentiality, and access of registry data are being addressed as registries are developed. Participation in immunization registries will continue to increase. The development of childhood immunization registries has widespread support among parents and providers66 and the required technology is becoming less expensive and simpler. Registries are part of the current trend to computerize medical data in the United States. To be successful, registries must be seamlessly integrated into the current provider environment and create no additional burdens. 14-27. (Developmental) Increase routine vaccination coverage levels of adolescents. Potential data source: National Health Interview Survey (NHIS), CDC, NCHS. Illness and disability caused by vaccine-preventable diseases, such as hepatitis B, measles, and varicella, continue among adolescents.25 While primary health care providers are vital to ensuring that infants and younger children are up to date on their vaccinations, they have an equally important role in ensuring comprehensive vaccination for adolescents.67 Any new universally recommended vaccine for adolescents should be at a 90 percent coverage level within 5 years of the recommendation. An estimated 79 percent of adolescents and children visit a health care provider annually.68 Providers such as nurses, nurse practitioners, pediatricians, family physicians, general practitioners, and emergency medicine specialists deliver most of the primary health care received by adolescents.69 Strategies should specifically target these providers to increase vaccination among adolescents, especially hard-to-reach and at-risk adolescents in urban and rural areas. School entry laws and regulations ensure high vaccination levels. Much of the experience to date in implementing adolescent vaccination comes from school-based hepatitis B demonstration projects.70 To encourage school participation in an adolescent vaccination program, a partnership between schools and local health departments is essential. Managed care organizations also have an increasingly important role in the delivery of health care services, including vaccinations, to adolescents. Measures for assessing immunization recommendations for adolescents have been incorporated into HEDIS 3.0.62 Such standards should greatly assist in implementing immunization recommendations for adolescents in the managed care setting. 14-28. Increase hepatitis B vaccine coverage among high-risk groups. Target and baseline:
Target setting method: 157 percent improvement for long-term hemodialysis patients; 567 percent improvement for men who have sex with men; 38 percent improvement for occupationally exposed workers. Hepatitis B vaccination has been recommended for persons with risk factors for hepatitis B virus infection since the vaccine was first licensed in 1981. These risk groups include the following: hemodialysis patients, men who have sex with men, incarcerated persons, health care and public safety workers who have exposure to blood in the workplace, persons with a history of sexually transmitted diseases or multiple sex partners, injection drug users, and household and sex contacts of HBV-infected persons. While data currently are not collected for inmates in long-term correctional facilities, it is recommended that prison officials should consider undertaking screening and vaccination programs directed at inmates with histories of high-risk behaviors. 14-29. Increase the proportion of adults who are vaccinated annually against influenza and ever vaccinated against pneumococcal disease. Target and baseline:
Target setting method: Better than the best.
Target setting method: Consistent with the Childhood Immunization Initiative.
Federal initiatives have highlighted the need to focus vaccination resources on adults.71 Vaccination is an effective strategy to reduce illness and deaths due to pneumococcal disease and influenza. Current levels of coverage among adults vary widely among age, risk, and racial and ethnic groups. Any new universally recommended vaccine should be at a 60 percent coverage level within 5 years of recommendation. Influenza and pneumococcal vaccines are covered by Medicare; thus vaccinating greater numbers of adults aged 65 years and older is feasible. High-risk adults aged 18 to 64 years may not have insurance coverage for influenza and pneumococcal vaccines. With the aging of the U.S. population, increasing numbers of adults will be at risk for these major causes of illness and death. Persons with high-risk conditions (that is, heart disease, diabetes, and chronic respiratory disease72, 73) remain at increased risk for these diseases, as do persons living in institutional settings. Continuing education of providers and the community is needed to increase awareness of and demand for adult vaccination services. Interventions, such as standing orders for vaccination, provider reminders and feedback, and patient notifications and reminders have been effective in increasing adult vaccination levels.21, 74 Guidelines and tools for implementing these interventions are available through Put Prevention Into Practice, a national campaign to improve delivery of clinical preventive services.75 Measurement and feedback about vaccination providers' performance in delivering vaccines enhance coverage rates. Providers should be given feedback on their performance in a timely manner. Measurement and feedback can result in improvements in vaccine coverage either by changing provider knowledge, attitudes, and behavior or by stimulating changes in the vaccine delivery system-for example, reminders and standing orders-or some combination. In addition, opportunities for vaccination outside of primary care and other traditional health care settings could be increased to reach elderly persons who do not routinely access primary care. For example, over 90 million emergency department visits are made in the United States annually. Emergency department vaccination is likely to increase vaccination rates among select populations difficult to vaccinate through office-based programs. In any nontraditional site, a method for tracking and communicating vaccinations is needed so that vaccination information may be shared with patients' primary care providers. 14-30. Reduce vaccine-associated adverse events. 14-30a. Eliminate vaccine-associated paralytic polio (VAPP).
Target: Zero cases. 14-30b. Reduce febrile seizures caused by pertussis vaccines.
Target: 75 febrile seizures. Because no natural reservoirs for wild poliomyelitis exist, VAPP is caused by the oral polio vaccine (OPV). With global polio eradication targeted for 2000, use of OPV should decrease and then stop, resulting in zero cases of VAPP. From 1980 to 1998, no indigeneous cases of paralytic poliomyelitis caused by wild polio virus transmission have occurred in the United States. However, 141 cases of VAPP have been reported in this same period, averaging 8 or 9 cases per year. Persons with VAPP experience the full range of illness and disability as well as loss of social function associated with being partially or fully paralyzed. Due to the progress in global poliomyelitis eradication and to the reduction of the burden of VAPP in the United States, ACIP recommended that beginning in 2000, only IPV will be used for routine immunization.76 In general, IPV is as effective as OPV and should be sufficient at preventing polio in the United States. Controlled clinical trials indicate that whole cell pertussis (wP) vaccines cause seizures at a frequency of 1 per 1,750 doses.37, 77, 78 The majority of these seizures are febrile seizures without any residual deficit. Nevertheless, such seizures-frightening patients and parents alike-frequently result in emergency department or other medical visits as well as costly diagnostic evaluations to rule out possible neurologic disorders. Recently licensed acellular pertussis (aP) vaccines are less likely to cause fever or seizures; data show seizure frequency of up to 1 per 14,280 doses.37 With the increasing use of aP vaccines, the number of pertussis vaccine-associated febrile seizures should be reduced by 50 percent. 14-31. Increase the number of persons under active surveillance for vaccine safety via large linked databases.
Target: 13 million persons. A high standard of safety is expected of vaccines since they are recommended for millions of healthy people, including infants. Vaccine safety monitoring to identify and minimize vaccine-related reactions is necessary to help ensure safety because no vaccine is completely safe. Knowledge of vaccine safety is essential to accurately assess the risks and benefits in formulating vaccine use recommendations. For example, the Institute of Medicine has reported that of 76 adverse events assessed, 66 percent had inadequate or no evidence available to accept or reject vaccine as a cause of the adverse reactions.79, 80 In collaboration with several health maintenance organizations, CDC has linked anonymous vaccination and medical records in a large database.81 This system is used to study vaccine safety, especially for evaluating new concerns arising from the Vaccine Adverse Event reporting System (VAERS) and other sources. These databases also are used for monitoring vaccine safety, conducting active surveillance of VPDs, carrying out vaccine safety and immunogenicity trials, evaluating vaccine economics, and assessing vaccine coverage. Related Objectives From Other Focus Areas
Published January 2000 Excerpted from: Department of Health and Human Services, Healthy People 2010 | | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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