American Journal of Epidemiology Advance Access originally published online on June 27, 2006
American Journal of Epidemiology 2006 164(3):197-199; doi:10.1093/aje/kwj205
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Vaccines—Victories and Challenges
1 Task Force for Child Survival and Development, Decatur, GA
2 Emory Vaccine Center, Emory University, Atlanta, GA
3 National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
Correspondence to Dr. Alan R. Hinman, Task Force for Child Survival and Development, 750 Commerce Drive, Suite 400, Decatur, GA 30030 (e-mail: ahinman{at}taskforce.org).
Received for publication April 24, 2006. Accepted for publication May 2, 2006.
The introduction and widespread use of vaccines has resulted in dramatic reductions in the incidence of many infectious diseases and has succeeded in the global eradication of smallpox. In the United States, immunization coverage levels among children are at all-time highs, and reported vaccine-preventable disease levels are at or near all-time lows, with the exception of pertussis. There have been no cases of paralysis due to indigenously acquired wild poliovirus since 1979, and indigenous transmission of both measles and rubella has been interrupted (1
). This year's issue of Epidemiologic Reviews, the sister publication of this journal, contains 11 articles reviewing a number of issues relating to vaccines and public health.
Grabenstein et al. (2) trace the history of immunization in the Armed Forces from the Revolutionary War, when variolation was initiated by General George Washington, to the current wars in Afghanistan and Iraq. They also highlight the contributions of scientists working for the Armed Forces to the development of many of the vaccines in use today, including vaccines against influenza, yellow fever, rubella, Japanese B encephalitis, meningococcal meningitis, and hepatitis A.
Three papers document some of the achievements made in control of viral hepatitis. Hepatitis B vaccine is the first vaccine that can prevent cancer, and this raises the possibility that vaccines may someday become a major focus in cancer prevention efforts. Shepard et al. (3) provide a global perspective on the epidemiology of hepatitis B and the progress made in reducing transmission of hepatitis B and hepatocellular cancer through the use of hepatitis B vaccine. In several countries, including the United States, there have been significant decreases in perinatal hepatitis B transmission as a result of universal immunization of newborns. Chien et al. (4) provide a detailed chronicle of the impact of hepatitis B vaccination in Taiwan. Since the beginning of universal immunization of newborns in 1986, there have been dramatic declines in hepatitis B surface antigen carriage rates and a significant decline in the occurrence of hepatocellular carcinoma in children. Both vertical (mother-to-child) and horizontal (child-to-child) transmission have decreased markedly.
Wasley et al. (5) describe the prevaccine epidemiology of hepatitis A around the world and the profound effect in the United States resulting from the introduction and widespread use of hepatitis A vaccine among young children in the 17 states with the highest reported incidence. The data show that children are major transmitters of the infection and that focusing on transmitters can have profound herd immunity effects. To reduce the remaining hepatitis A burden, the Advisory Committee on Immunization Practices recently recommended universal immunization of young children throughout the United States (6).
Three articles address issues relating to influenza vaccines. Ompad et al. (7) review the literature published since 1990 on delivery of influenza vaccine to groups at high risk of complications from the disease. Several interventions have reportedly improved coverage—advertising, provider and patient mailings, registry-based telephone calls, patient and staff education, standing orders coupled with use of standardized forms, targeting of syringe-exchange customers, and visiting nurses. The Task Force on Community Preventive Services conducted systematic reviews of the literature published from 1980 to 2000 on interventions designed to improve coverage with influenza, pneumococcal polysaccharide, and hepatitis B vaccines among high-risk adults (8). The Task Force found that evidence was sufficient to recommend only one intervention implemented alone—provider reminders.
Naleway et al. (9) reviewed the available literature and outlined studies needed to identify interventions for improving delivery of influenza vaccine to pregnant women. They provide a useful systems approach to the consideration of barriers and enabling factors. They also point out the need for obstetrician-gynecologists to better appreciate the increased risks of complications of influenza and the safety of influenza vaccination during pregnancy. Improved mechanisms for delivery of influenza vaccine in obstetrical care practices are also needed.
The Advisory Committee on Immunization Practices recently recommended annual influenza immunization of all children between the ages of 6 months and 5 years because of their increased risk of complications and hospitalization from influenza (10). There is increasing discussion about annual influenza immunization of schoolchildren to reduce transmission and blunt the impact of annual influenza epidemics (11–15). Coleman et al. (16) describe the interdisciplinary epidemiologic and economic research needed to support such a policy.
Because long-term vaccination follow-up studies are usually not available at the time that vaccines are licensed and vaccination policy is established, mathematical models may be the only way to assess long-term effects that policy-makers must consider. Dasbach et al. (17) reviewed the literature on mathematical modeling of human papillomavirus disease for evaluating the potential impact of human papillomavirus vaccination policies, primarily on cervical cancer. They found considerable variation in the types of models used, the factors considered, and the questions answered. They recommend that future research focus on further development of dynamic models to assess the cost-effectiveness of alternative human papillomavirus vaccination policies.
Salmon et al. (18) review the different approaches used to estimate vaccination coverage among preschool-age children in the United States and the strengths and weaknesses of each. The principal means currently employed, the National Immunization Survey, uses a random-digit-dialing approach that may become increasingly difficult as more and more people use alternative types of telephones that are not reachable through this technique. They point out the potential future utility of immunization registries as a means of monitoring coverage on a real-time basis.
Menzies and McIntyre (19) summarize information on the epidemiology of vaccine-preventable diseases, the vaccination strategies used, and their impact in indigenous populations of the United States, Canada, Australia, and New Zealand. Vaccination strategies for reaching these groups have not always been successful, particularly for those living in urban settings.
Robinson et al. (20) summarize approaches to using and interpreting serologic information on rubella immunity. The complexities involved in serologic testing for rubella immunity include estimating a protective titer and implementing programs that follow up on seronegative women. The difficulties highlight the importance of eliminating rubella transmission, thereby protecting pregnant women indirectly by decreasing exposure to the virus. Rubella transmission has been interrupted in the United States using an approach of widespread vaccination of children and more limited vaccination of adults (21).
In sum, these 11 articles provide a fascinating account of some of the medical victories obtained with vaccines and some of the challenges that still await. Of course, this is only a partial list of both the victories and the challenges. The large 2006 US outbreak of mumps, which as of this writing has not been fully explained, serves as a reminder of the critical role that science needs to play in guiding vaccination strategy and outbreak response, as well as in vaccine research and development (22).
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ACKNOWLEDGMENTS |
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Dr. Walter A. Orenstein receives grant support for research from the Chiron Foundation (Emeryville, California), Merck & Company (New York, New York), and Sanofi Pasteur (Lyon, France). He is a consultant for the data safety monitoring boards of the Covalent Group (Wayne, Pennsylvania) and the DynPort Vaccine Company (Frederick, Maryland).
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References |
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- Orenstein WA, Douglas RG, Rodewald LE, et al. Immunizations in the United States: success, structure, and stress. Health Aff (Millwood) 2005;24:599–610.
[Abstract/Free Full Text] - Grabenstein JD, Pittman PR, Greenwood JT, et al. Immunization to protect the U.S. Armed Forces: heritage, current practice, prospects. Epidemiol Rev 2006;28:3–26.
[Abstract/Free Full Text] - Shepard CW, Simard EP, Finelli L, et al. Hepatitis B virus infection: epidemiology and vaccination. Epidemiol Rev 2006;28:112–25.
[Abstract/Free Full Text] - Chien YC, Jan CF, Kuo HS, et al. Nationwide hepatitis B vaccination program in Taiwan: effectiveness in the 20 years after it was launched. Epidemiol Rev 2006;28:126–35.
[Abstract/Free Full Text] - Wasley A, Fiore A, Bell BP. Hepatitis A in the era of vaccination. Epidemiol Rev 2006;28:101–11.
[Abstract/Free Full Text] - Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention. Provisional recommendations for hepatitis A vaccination of children. Atlanta, GA: Centers for Disease Control and Prevention, 2005. (http://www.cdc.gov/nip/recs/provisional_recs/hepA_child.pdf). (Accessed April 17, 2006).
- Ompad DC, Galea S, Vlahov D. Distribution of influenza vaccine to high-risk groups. Epidemiol Rev 2006;28:54–70.
[Abstract/Free Full Text] - Task Force on Community Preventive Services. Recommendations to improve targeted vaccination coverage among high-risk adults. Am J Prev Med 2005;28(suppl):231–7.[CrossRef][ISI][Medline]
- Naleway AL, Smith WJ, Mullooly JP. Delivering influenza vaccine to pregnant women. Epidemiol Rev 2006;28:47–53.
[Abstract/Free Full Text] - Centers for Disease Control and Prevention. CDC's Advisory Committee recommends expanded influenza vaccinations for children. (Press release, February 23, 2006). Atlanta, GA: Centers for Disease Control and Prevention, 2006. (http://www.cdc.gov/od/oc/media/pressrel/r060223.htm). (Accessed April 17, 2006).
- Belshe RB. The direct benefits of vaccinating healthy children with inactivated or live attenuated influenza vaccines. Presented at the conference "Universal Vaccination against Influenza: Are We Ready?," Atlanta, Georgia, October 24–25, 2005. Atlanta, GA: Exploratory Center for Interdisciplinary Research in Vaccinology, Emory University School of Medicine, 2005. (http://www.medicine.emory.edu/id/ecirve/areweready.html). (Accessed April 17, 2006).
- Monto AS. Indirect benefits of vaccinating children >23 months of age with inactivated vaccines. Presented at the conference "Universal Vaccination against Influenza: Are We Ready?," Atlanta, Georgia, October 24–25, 2005. Atlanta, GA: Exploratory Center for Interdisciplinary Research in Vaccinology, Emory University School of Medicine, 2005. (http://www.medicine.emory.edu/id/ecirve/areweready.html). (Accessed April 17, 2006).
- Glezen WP. Indirect benefits of vaccinating children >23 months of age with live attenuated vaccines. Presented at the conference "Universal Vaccination against Influenza: Are We Ready?," Atlanta, Georgia, October 24–25, 2005. Atlanta, GA: Exploratory Center for Interdisciplinary Research in Vaccinology, Emory University School of Medicine, 2005. (http://www.medicine.emory.edu/id/ecirve/areweready.html). (Accessed April 17, 2006).
- Longini IM Jr. Impact of universal vaccination of children on community influenza in a mathematical model. Presented at the conference "Universal Vaccination against Influenza: Are We Ready?," Atlanta, Georgia, October 24–25, 2005. Atlanta, GA: Exploratory Center for Interdisciplinary Research in Vaccinology, Emory University School of Medicine, 2005. (http://www.medicine.emory.edu/id/ecirve/areweready.html). (Accessed April 17, 2006).
- Meltzer MI. Cost-effectiveness analysis of universal vaccination of children >23 months of age. Presented at the conference "Universal Vaccination against Influenza: Are We Ready?," Atlanta, Georgia, October 24–25, 2005. Atlanta, GA: Exploratory Center for Interdisciplinary Research in Vaccinology, Emory University School of Medicine, 2005. (http://www.medicine.emory.edu/id/ecirve/areweready.html). (Accessed April 17, 2006).
- Coleman MS, Washington ML, Orenstein WA, et al. Interdisciplinary epidemiologic and economic research needed to support a universal childhood influenza vaccination policy. Epidemiol Rev 2006;28:41–6.
[Abstract/Free Full Text] - Dasbach EJ, Elbasha EH, Insinga RP. Mathematical models for predicting the epidemiologic and economic impact of vaccination against human papillomavirus infection and disease. Epidemiol Rev 2006;28:88–100.
[Abstract/Free Full Text] - Salmon DA, Smith PJ, Navar AM, et al. Measuring immunization coverage among pre-school children: past, present and future opportunities. Epidemiol Rev 2006;28:27–40.
[Abstract/Free Full Text] - Menzies R, McIntyre P. Vaccine preventable diseases and vaccination policy for indigenous populations. Epidemiol Rev 2006;28:71–80.
[Abstract/Free Full Text] - Robinson JL, Lee BE, Preiksaitis JK, et al. Prevention of congenital rubella syndrome—what makes sense in 2006? Epidemiol Rev 2006;28:81–7.
[Abstract/Free Full Text] - Elimination of rubella and congenital rubella syndrome—United States, 1969–2004. MMWR Morb Mortal Wkly Rep 2005;54:279–82.[Medline]
- Exposure to mumps during air travel—United States, April 2006. MMWR Morb Mortal Wkly Rep 2006;55:401–2.[Medline]
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