IMMUNIZ

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Lance Chilton, M.D.Professor, PediatricsUniversity of New Mexico

THE REASON WE IMMUNIZE

Achievements in Public Health, 1900-1999 Impact of Vaccines Universally Recommended for Children -- United States, 1990-1998 At the beginning of the 20th century, infectious diseases were widely prevalent in the United States and exacted an enormous toll on the population. For example, in 1900, 21,064 smallpox cases were reported, and 894 patients died (1). In 1920, 469,924 measles cases were reported, and 7575 patients died; 147,991 diphtheria cases were reported, and 13,170 patients died. In 1922, 107,473 pertussis cases were reported, and 5099 patients died (2,3).

Dramatic declines in morbidity have been reported for the nine vaccine-preventable diseases for which vaccination was universally recommended for use in children before 1990 (excluding hepatitis B, rotavirus, and varicella) . Morbidity associated with smallpox and polio caused by wild-type viruses has declined 100% and nearly 100% for each of the other seven diseases.

MMWR, April 2, 1999

Q: WHAT IS STILL THE MOST COMMON VACCINE-PREVENTABLE DISEASE?

A: INFLUENZAAKA: “JUST THE FLU”

Average Annual United States Incidence of Influenza Outcomes

Under 5 Years 5-17 Years Total Population

“Just sick” 2,030,000 3,296,000 12,414,000

Outpatient visit

1,741,000 1,535,000 7,282,000

Hospitalized 54,343 2,805 195,776

Deaths 142 43 21,282

Molinari et al. Vaccine 25 (2007) 5086–5096

INFLUENZA DEATHS IN CHILDREN

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NEW MEXICO’S SCHOOL KIDS’ INFLUENZA IMMUNIZATION PROJECT

KUDOS TO SKIIP AND TO ALL OF YOU!

Age 5-12All Under 17

0

20

40

60

80

Flu Vaccine in Kids

USNew Mexico

EARLY ALBUQUERQUE DATA: FLU SCHOOL ABSENCES

01

002

003

004

005

00

0 10 20 30 40 50week

week_Full_Day_IL week_Half_Day_ILtotal_flu

Gurule, Escareno, Dharas, Pentler, Skipper and Chilton, unpublished

DOESN’T H

E EVER S

TOP

TALK

ING A

BOUT

INFL

UENZA?

HE

DO

ES

.

WHERE DO IMMUNIZATION RECS COME FROM?

• American Academy of Pediatrics Committee on Infectious Diseases (Red Book Committee) : meets twice a year, produces Red Book every 3 years

• ACIP – Next Meeting: June 25-26, 2014, Atlanta• Informational items• Votes

RED BOOK COMMITTEE

Screen for Powerpoints

Head Table

Members

M ML

Liaisons

L

Audience

Audience

Audience

Podium

ACIP

Jonathan Tempte Larry Pickering

www.cdc.gov/vaccines

ACIP Products

A BIT

ABOUT

VACCIN

E

SAFETY

ARE VACCINES SAFE?

AND WHAT’S VAERS ANYWAY?

Vaccine Adverse Effects Reporting System

VSD

THE VACCINE SAFETY DATALINK

This is the most robust vaccine safety system; there are others (example: military).

THE ROTASHIELD® STORY (BORN 1998, DIED 1999)

• Rotavirus kills some 450,000 children per year around the world; 20-60 in the United States

• Early 1990s , clinical trials showed 80-100% effectiveness against severe rotavirus diarrhea and excellent safety profile

• 1998: RotaShield licensed

• Late 1998: reports to VAERS of many cases of intussusception after RotaShield receipt

• VAERS Signal reported to VSD, which affirmed the hypothesis that RotaShield associated with intussusception

• 1999: Rotashield removed from market.

• Early 2000s, clinical trials on far more children showed no association with intussusception for two new vaccines, Rotarix® and Rotateq®

• 2006: Rotarix and Rotateq approved by FDA and recommended by ACIP

SUCCESS OR FAILURE OF THE VACCINE SAFETY SYSTEM?

HOW S

HOULD W

E

COMMUNICAT

E HOW

SAFE

VACCIN

ES ARE?

PENN AND TELLER’S APPROACH

TO VACCINE SAFETY DISCUSSION

Viewer Discretion Advised

PAUL OFFITT’S APPROACH

DR. BOB SEARS’APPROACH

DR. SEARS’ VACCINE SCHEDULE

TOO MANY ANTIGENS?

2012: 2 month shots:

Antigens:

Rotavirus 5

Pediarix Diphtheria 1 Tetanus 1 Pertussis 3 Polio 3 Hepatitis B 1

H. Influenzae B 1

Pneumococcal 13

Total 28

Streptococcal Infection =

25-50 antigens

Upper respiratory

infection =

4-10 antigens

In the old days:

Smallpox vaccine =

~200 antigens

Whole cell pertussis vaccine =

~3000 antigens

DECLINING NUMBER OF ANTIGENS:

VACCIN

ES A

REN’T

FREE

But no, folks, you won’t have to pay for vaccines in New Mexico (yet).

IN 42 STATES…

But only for

• Uninsured

• Native Americans/Alaska Natives

• Medicaid insured

• Underinsured• But only in FQHC or

RHC

IN 6 STATES (NH, RI, VT, WI, WY AND…

For all children and adolescents before their 19th birthday

NEW MEXICO!)

Alaska, Hawaii, Maine, Massachusetts, South Dakota, Washington cover most but not all childhood vaccines

ARE THESE VACCINES AFFORDABLE?

In Arizona, Colorado, Utah, Texas and most other states, the total private sector price of all vaccines for each person (except influenza) through age 18 was $2171 + vaccine administration as of April 2014.

In New Mexico, the price to patients is $0 + vaccine administration

Vaccines for Children for everyone in New Mexico is under attack!

Vaccine

Doses Total

Pediarix

3 $211

Rotateq

3 $226

Hib 4 $93

Pneumo

4 $543

MMR 2 $112

Varivax 2 $188

Hep A 2 $61

DTaP 2 $21

Polio IPV

1 $27

TOTAL $1482

Vaccine

Doses Total

Gardasil 3 $425

Menactra

2 $226

Tdap 1 $38

TOTAL $689

WHY IS THIS IMPORTANT?

Vaccines for the first five years

Vaccines for adolescence

Vaccine Total Cost per Child

$2171

plus Influenza Vaccine, $8-23/doseApril 1, 2014, CDC data

IS IT WORTH IT? FIGURES FOR ONE BIRTH COHORT – 2009: 4.26 MILLION BIRTHS

Disease Cases PreventedDeaths

Prevented

Direct Costs Saved, Million

$

Societal Costs Saved (Direct +

Indirect), Million $

Diphtheria 275 028 27 503 3654 39 296

Tetanus 169 25 12 45

Pertussis 2 950 836 1062 4443 7017

Hib 19 606 741 1810 3756

Polio 67 463 800 2898 7259

Measles 3 835 825 3106 3762 8862

Mumps 2 312 275 12 1411 2374

Rubella 1 981 066 15 187 721

Congenital rubella syndrome

632 70 133 257

HepB 239 993 3514 240 1770

Varicella 3 942 546 73 373 1598

HepA 153 164 36 52 114

Pneumococcus-related diseasesb

2 323 952 5056 965 2696

Rota 1 582 940 19 327 595

Total 19 685 495 42 032 20 267 76 360

DEATHSTHAT’S $20 BILLION and $76 BILLION!

Cost:benefit ratio

Direct costs only: 3.0Total societal costs: 10.1

Zhou F et al. Economic Evaluation of the Routine Childhood Immunization Program in the US, 2009. Pediatrics, 2014. 133:577.

RESULTS…

VFCVACCINE

VACCINEfor

everyone else

$90,000

THAT

’S T

HE BUSIN

ESS

SIDE; H

OW A

BOUT TH

E

PERSONAL C

ONTEXT?

THIS IS WHY WE DO IT…

Disease Annual Cases – Pre-Vaccine Era

Annual CasesSince Vaccine

PercentReduction

Diphtheria 175,885 0 100%

Tetanus 1314 28 98%

Measles 503,282 43 99.9%

Mumps 152,209 800 99.5%

Rubella 47,745 12 99.9%

Congenital Rubella Syndrome

823 0 100%

Polio 16,316 0 100%

Haemophilus influenzae b

20,000 54 99.7%

MY PA

TIEN

T, P

OST HIB

MENINGIT

IS

Age 34

HOW’RE WE DOING ON INDIVIDUAL ADOLESCENT VACCINES?

Rotav

irus

2nd

Varic

ella

TdaP

Men

ing

Conj

1st H

PV g

irls

3rd

HPV g

irls

1st H

PV b

oys

3rd

HPV b

oys

0102030405060708090

NMUS

?

CDC 2012 NIS data in MMWR, Aug. 30, 2013

UK908070605040302010

HOW DO THEY DO THAT?

Vaccines for Children for everyone in New Mexico is under attack!

CERVICAL CANCER IN NEW MEXICO

Incidence

 

Race/EthnicityAge-adjusted

rateAverage number of

new casesPercent of all

new cases

Rank among all new cancer cases†

NM, Non-Hispanic White 6.5 32 1.3% 13

NM, Hispanic 9.0 35 2.8% 10NM, American Indian 6.5 6 2.7% 13

NM, Black 5.2 1 2.0% 11NM, All Races Combined * 76 1.9% *

US, All Races Combined§ 7.4 11,070 1.6% 13

Mortality

 

Race/EthnicityAge-adjusted

rateAverage numberof cancer deaths

Percent of allcancer deaths

Rank among all cancer deaths†

NM, Non-Hispanic White 1.7 10 1.1% 15

NM, Hispanic 3.1 12 2.6% 12NM, American Indian 3.5 3 3.5% 10NM, Black - - - -NM, All Races Combined * 26 1.7% *

US, All Races Combined§ 2.4 3,870 1.4% 14

New Mexico Tumor Registry, 2006-2010 data

Prevalence of individual human papillomavirus (HPV) types among females aged 14–19 years, 2003–2006 and 2007–2010.

Markowitz L E et al. J Infect Dis. 2013;208:385-393

Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2013.

SPECIA

L COMMUNIQ

UÉ

FROM T

HE FRONT

HPV VACCINATION DOES NOT CAUSE TEENAGERS TO HAVE SEX

Mayhew A et al. Sexual Behaviors after HPV Vaccination. Pediatrics, 2014. 133:404.

Yes• That’s

where the kids are!

• We could teach about the diseases prevented

No• School

nurses already have too many tasks

• Some vaccines are too controversial

SHOULD WE GIVE MORE VACCINES IN NEW MEXICO SCHOOLS?

THANK YOU FOR ALL YOU DO!

"Schools have a wealth of potential for ensuring the future well-being of young people. You can't educate a child who isn't healthy, and you can't keep a child healthy who isn't educated."

-- M. Jocelyn Elders, MD