The Future of Immunization

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The Future of Immunization
AIM Annual MeetingAtlanta, GADecember 6, 2006

• Anne Schuchat, MD
• Rear Admiral, US Public Health ServiceDirector,
  National Center for Immunization and Respiratory
  Diseases (proposed)Centers for Disease Control
  and PreventionAtlanta, GA

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• Where are we?

Where are we going?
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National Center for Immunization and Respiratory
Diseases (proposed)

• Mission
• Prevention of disease, disability, and death
  through immunization and by control of
  respiratory and related diseases.

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NCIRD Organization(proposed)
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NCIRD and CCID

• NCIRD synthesizes most expertise in VPDs,
  immunization, and acute respiratory infections
• Collaborates with
• HPV, Hepatitis A and B SMEs located in NCHHSTP
• Rabies, smallpox, yellow fever, JE, typhoid
  vaccine SMEs located in NCZVED
• Immunization Safety Office located in CDCs
  Office of the Chief Science Officer

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Comparison of 20th Century Annual Morbidity and
Current Morbidity Vaccine-Preventable Diseases
Source CDC. MMWR April 2, 1999. 48
242-264 Source CDC. MMWR. August 18, 2006
/ 55(32)880-893 Imported vaccine-associated
paralytic polio (VAPP) Type b and unknown (lt
5 years of age)
Numbers in yellow indicate at or near record
lows in 2005
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Comparison of Pre-Vaccine Era Estimated Annual
Morbidity and Current Estimated Morbidity
Vaccine-Preventable Diseases
Unpublished CDC data, reported November 2006

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Return on Investment of Childhood Immunization
Program

• For each birth cohort vaccinated with 7 vaccines
  (DTaP, Td, Hib, Polio, MMR, Hep B, Varicella)
  routinely included in the schedule
• Society saves 33.4B in indirect costs
• Direct health care costs are reduced by 9.9B
• 33,000 lives are saved
• 14M cases of disease are prevented

Source Zhou et al Archives of Pediatric and
Adolescent Medicine 2005
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Eliminating Racial Disparity in Immunization
Coverage 431331 Estimated Vaccination
Coverage by Race/Ethnicity, 19-35 Month Old
Children, US
National Immunization Survey, MMWR Sept 14, 2006
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Increasing Vaccine-Specific Coverage Rates Among
Preschool-Aged Children
2010 Target
DTP(3)
Hep B (3)
PCV 7 (3)
MMR(1)
Polio (3)
Hib (3)
Varicella (1)
2005
DTP(3) is not a Healthy People 2010 objective.
DTP(4) is used to assess Healthy People 2010
objectives. Note Children in the USIS and NHIS
were 24-35 months of age. Children in the NIS
were 19-35 months of age. Source USIS
(1967-1985), NHIS (1991-1993) CDC, NCHS, and NIS
(1994-December 2003), CDC, NIP and NCHS No data
from 1986-1990 due to cancellation of USIS
because of budget reductions.
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Estimated Vaccination Coverage with 3 PCV, by
Coverage Level and StateNational Coverage 83
VT 89
85
? 90
80-89
70-79
? 69
3 doses Pneumoccocal Conjugate vaccine
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Health and Economic Effects of PCV7 in first 5
Years of Use

• Base analysis PCV7 averted 38,000 cases of
  invasive pneumococcal disease (IPD) in first 5
  years at 112,000 per life year saved
• Analysis w/ observed herd effects PCV7 averted
  109,000 cases of IPD at 7,500 per life year saved

Ray GT et al. Pediatr Infect Dis 2006
25(6)494-501
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Policy Decisions 2005-2006
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OUTBREAK !
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Week of Onset for Mumps Cases, United States,
January 1September 9, 2006 (n5594)1
1 National Notifiable Diseases Surveillance
System (data provisional)
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Number and Incidence of Mumps in the Seven
Highly Affected States, January 1- September 9,
20061

• State Reported Cases
• Iowa 1955
• South Dakota 287
• Kansas 883
• Nebraska 355
• Wisconsin 750
• Illinois 574
• Missouri 155
• (89)

Incidence/105 66 37 32 20 14 5 3
1 National Notifiable Diseases Surveillance
System (data provisional)
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Incidence of Mumps by Age Group, United States,
January 1 September 9, 2006 (n5594)1
1 National Notifiable Diseases Surveillance
System (data provisional)
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Expanded ACIP Targets for Influenza Vaccine Size
of Recommended Groups
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Important Challenges

• Unpredictable production
• Multiple products and formulations
• Importance of timing of vaccine availability
• Inherent challenge in balancing supply and
  demand/utilization

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Influenza Vaccine Production and Distribution,
US, 1980-2005
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Influenza Vaccine Production and Distribution,
US, 1980-2005
2006/7 Vaccine Season Largest Number of Doses
Ever Distributed
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Cumulative Influenza Vaccine Distribution, US,
2000-2006
November doses as of 11/24
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National Influenza Vaccination Week

• November 27 December 3, 2006

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• Where are we going?

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NEW
PRODUCTS
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Number of Vaccines in the Routine Childhood and
Adolescent Immunization Schedule
1985
1995
2006
Measles Rubella Mumps Diphtheria Tetanus Pertussis
Polio Hib (infant) HepB Varicella
Measles Rubella Mumps Diphtheria Tetanus Pertussis
Polio Hib (infant) HepB Varicella Pneumococcal
disease Influenza Meningococcal
disease HepA Rotavirus HPV
Measles Rubella Mumps Diphtheria Tetanus Pertussis
Polio
7
10
16
Provisional ACIP recommendation, not yet
published
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Completely New Vaccines, Important Prevention
Targets

• Rotavirus vaccine for infants
• hospitalizations, severe diarrheal episodes
• Human papilloma virus vaccine for teenaged girls
• cervical cancer, precancerous lesions, genital
  warts
• Zoster vaccine for seniors
• shingles, postherpetic neuralgia

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Federal Contract Prices for Vaccines Recommended
Universally for Children and Adolescents 1985,
1995, 2006
1182
155
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Federal contract price shown for 1985 and 1995
are averages that account for price changes
within that year.
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For Girls Only

• HPV vaccine is first routine vaccine in US
  recommended only in girls or women
• Opportunities for new outreach and partners

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Population Groups
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New Population Groups
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Where Can We Make Big Gains?

• Implementing package of immunizations for
  adolescents Menactra, Tdap, HPV
• Improving adult vaccine coverage influenza, 23-V
  PPV
• Implementing new adult recs Tdap booster, HPV
  catch-up

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Where Can We Make Big Gains?

• Implementing package of immunizations for
  adolescents Menactra, Tdap, HPV
• Improving adult vaccine coverage influenza, 23-V
  PPV
• Implementing new adult recs Tdap booster, HPV
  catch-up
• Transforming hepatitis B prevention in adults

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Incidence of Acute Hepatitis B, by Age, United
States, 1990-2005
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Prior Opportunities For Vaccination Among
Patients With Acute Hepatitis B, 2001-2003
Sentinel Counties Study of Viral Hepatitis (n483)
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NEW Partnerships
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Public Health Partnerships

• Hepatitis, HIV, STD control programs
• hepatitis B vaccination at venues reaching high
  risk groups
• Preparedness programs
• flu vaccination drills
• Surveillance programs
• linking epi/lab/program to monitor impact
• new vaccine disease indicators complex

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Expanded Public-Private Partnerships

• Occupational health
• employer-based vaccination
• Healthcare systems
• HCW vaccinations (influenza, Tdap, Hep B)
• Retail settings
• surge for flu vaccine, ? role in adolescent
  immunization
• Community-organizations
• Faith-based, Girls clubs?

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Wave of the Future The Future is Now

• Immunization Information Systems (registries),
  Health IT and Electronic Medical Record
• Vaccine Business Management Improvement Project
  (VMBIP)

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Thank you!