20.1 For the six vaccine-preventable diseases with a Healthy People 2000
target of zero cases, 1998 data show the following: one case of diphtheria among people aged <25
(no change from the 1988 baseline); nine cases of tetanus among people aged <25 years (an increase
of three cases from the 1988 baseline); zero cases of polio caused by wild virus (no change from
the 1988 baseline); 100 cases of measles (continuing a downward trend from the 1988 baseline of
3,396 cases); 364 cases of rubella (an increase from the 1988 baseline of 225 cases); and seven
cases of congenital rubella syndrome (a slight increase from the 1988 baseline of six cases). The
number of cases of measles, rubella and congenital rubella syndrome rose sharply in the early
1990s, but has since declined. The incidence of mumps decreased from 4,866 cases in 1988 to 666 cases in 1998, nearing the target of 500 cases. The incidence of pertussis reached 7,796 cases in 1996 and showed a general increase
over the decade from 3,450 cases in 1988 to 7,405 cases in 1998, moving away from the target of 1,000 cases.
20.2 Tracked in 3-year moving averages, the rate of epidemic-related
pneumonia and influenza deaths among people aged 65 and over fluctuated during the decade of the
1990s, reaching an average low of 15.7 cases per 100,000 in 1991-93 (target, 15.9 cases per 100,000).
More recently, the 3-year average rate in 1994-96 was 17.3 cases per 100,000.
20.3 The estimated incidence of hepatitis A infection fluctuated in the 1990s
ranging from 43.3 cases per 100,000 in 1989 to 27.2 cases per 100,000 in 1992. The overall rate decreased from 33.0 cases per 100,000 in 1987 to 25.8 in 1998, nearing the year 2000 target of 16.1 cases per 100,000. The
rate of hepatitis A among Hispanics increased to 72.6 cases per 100,000 in 1997, before decreasing
to 41.0 in 1998, nearing the target of 26.9. The rate among American Indians/Alaska Natives declined
dramatically from 256.0 cases per 100,000 in 1992 to 30 per 100,000 in 1998, surpassing the target
of 128.
The estimated incidence of hepatitis B decreased from 63.5 cases per 100,000 in 1987 to 22.5
cases per 100,000 in 1998 (target, 40). Targets set for special populations have also been achieved
for all groups except heterosexually active people, men who have sex with men, and children of
Asians/Pacific Islanders, although the estimated number of hepatitis B cases among the third group
decreased from 10,817 cases in 1987 to 4,281 in 1998 (target, 1,500).
The overall estimated rate of
hepatitis C declined from 18.3 cases per 100,000 in 1987 to 2.4 cases per 100,000 in 1997, surpassing
the target of 13.7. Among Hispanics, the rate of hepatitis C declined from 17.2 cases per 100,000 in
1992 to 7.7 in 1996 (target, 13.7).
20.4 From 9.1 cases per 100,000 in 1988, the tuberculosis case rate in the
U.S. rose to 10.5 in 1992, then decreased to 6.8 in 1998, well above the year 2000 target of 3.5.
Among special populations, the rate also fluctuated during this period, although these populations
continue to have higher rates than the entire U.S. population. In 1998, the rate for
Asians/Pacific Islanders was 36.6 cases per 100,000 (target, 15.0); for Blacks, 17.8
(target, 10.0); for Hispanics, 13.6 (target, 5.0); and for American Indians/Alaska Natives,
12.6 (target, 5.0). The resurgence of tuberculosis from 1985 to 1992 was associated with the
HIV epidemic, imported cases from immigrants from tuberculosis-endemic areas, and the occurrence
of multi-drug resistant strains of the disease.
20.5 In 1999, preliminary data show that the surgical wound infection
rate was 1.4 per 100 operations for low-risk patients (compared with 1.1 in 1986-90 and the
year 2000 target of 1.0); 2.3 for medium-low-risk patients (3.2 in 1986-90, with the target
of 2.9); 3.9 for medium-high-risk patients (6.3 in 1986-90, with the target of 5.7); and 5.7
for high-risk patients (14.4 in 1986-90, with the target of 13.0). Thus, only the target for
low-risk patients appears not to have been met.
20.7 The rate of infection with bacterial meningitis decreased from 6.5
cases per 100,000 in 1986 to 1.9 in 1998, well below the year 2000 target of 4.7. Among Alaska
Natives, a group particularly at risk, the infection rate fell from 33 cases per 100,000 in 1987
to 6.0 in 1996, also below its target of 8 cases per 100,000. (See chart following.)
20.11 In 1998, vaccination coverage at a national level among children
aged 19-35 months was 96% with diphtheria-tetanus-pertussis or DTP (three or more doses); 91% with
poliovirus vaccine; 92% with measles-mumps-rubella (MMR); 93% with Haemophilus influenzae type b or
Hib (three or more doses); 87% with hepatitis B (three or more doses); and 81% with the combined
series 4DTP/ 3polio/1MMR. (See chart.) However, not all geographic areas and population subgroups
achieved the year 2000 target of 90% for each vaccine type.
In 1997, the rate of pneumococcal vaccination among non-institutionalized
people aged 65 years and older was 43%, 22% for Blacks, and 23% for Hispanics. The comparable
baseline levels in 1989 were 15%, 6% and 11%, respectively. The year 2000 target is 60%. The
influenza vaccination coverage rate for non-institutionalized people aged 65 years and older
was 63% in 1997 ( 33% in 1989), exceeding the target of 60%. However, the rate for Blacks in that
age group in 1997 was only 45% (20% in 1989), and for Hispanics, 53% (28% in 1989).
20.18 The proportion of infected people who had completed preventive
therapy for tuberculosis changed little over the decade; it was 66.3% in 1987 and 62.2% in 1997.
The year 2000 target is 85%.
DEVELOPMENTS
- Since 1995, three expert groups—the Advisory Community on Immunization Practices,
the American Academy of Pediatrics, and the American Academy of Family Physicians—have collaborated to issue a single childhood immunization schedule. Recommended
immunization schedules have also been issued for adolescents and adults. Improved vaccination
coverage levels have led to the decreased incidence of vaccine-preventable diseases.
- In the 1980's, Haemophilus influenzae b (Hib) was the leading cause of childhood
bacterial meningitis and postnatal mental retardation. Since licensure ten years ago of conjugate
vaccines against Hib for use in infants and young children, the number of cases of Hib invasive
diseases in children under 5 years of age has declined by 99 percent.
- Almost 60 percent of respondents to a survey by the Health Care Financing Administration reported
that they had never received a pneumococcal vaccination and nearly one-third were unaware that
immunization against pneumococcal disease is recommended for all older adults.
- Between 1985 and 1992, new cases of tuberculosis increased by 20 percent. This necessitated
a rebuilding of the network for diagnosis, treatment and follow-up of cases and contacts, resulting
in a 30 percent decline in new cases over the last six years.
- From 1993 to 1998, 45 States and the District of Columbia reported cases of multi-drug resistant
tuberculosis. In 1993, almost 3 percent of new tuberculosis cases were of the multi-drug resistant type,
and one or more such cases were reported by 36 States and the District of Columbia. However, the
percentage of multi-drug resistant cases had been reduced to 1.1 percent by 1998.
- Under the Vaccines for Children (VFC) program, CDC assists States in distributing vaccine to over
40,000 provider sites, 70 percent of which are in the private sector. In 1997, 75 percent of all children
19-35 months of age received some or all vaccinations from a VFC-enrolled
provider.
RECOMMENDED ACTION
- Augment surveillance of infectious diseases, with particular
attention to emerging,
re-emerging, antimicrobial resistant, and newly vaccine preventable diseases.
- Increase research aimed at counteracting antimicrobial resistance.
- Through public education campaigns, provide accurate information on the actual benefits
and risks of vaccination.
- Support additional research to develop a safe and effective vaccine against
tuberculosis and to devise new methods to test for latent tuberculosis infection.
- With new acellular pertussis vaccines now available to protect infants and young children
from pertussis, increase efforts to make such vaccines available for adolescents and adults.
- Expand development of immunization registries in all 50 States. In addition to enabling
providers to have complete and accurate vaccination histories at their fingertips, registries should
be able to accurately access vaccination coverage rates at the local or population level, increase
coverage through reminder/recall notices to parents, and assist with vaccination decision-making
by providing automated decision support.
- Forge partnerships to provide common gateway sites for immunizing adults (as schools do for
children), for example, at workplaces.
- Ensure that culturally and linguistically competent services and staff are readily available to
provide information about infectious diseases and immunizations to members of ethnic minorities,
particularly those who are recent immigrants.
- Increase public awareness that many common fevers and respiratory ailments are not amenable to
effective treatment with antibiotics.
- Provide additional resources to ensure that cases of tuberculosis are diagnosed, reported and
treated in a timely fashion and that follow-up services are available to guarantee a successful
course of therapy.
PARTICIPANTS
Advisory Council on Elimination of Tuberculosis
Alabama Department of Public Health
American Academy of Pediatrics
American Lung Association
American Society for Microbiology
Association of Public Health Laboratories
Association of State and Territorial Health Officials
Centers for Disease Control and Prevention
Congress of National Black Churches
Eli Lilly Company
Infectious Diseases Society of America
Mayo Clinic and Foundation
National Coalition for Adult Immunization
National Vaccine Advisory Committee
Office of Disease Prevention and Health Promotion
Office of Public Health and Science
Office on Women's Health
Pan American Health Organization
Pulmonary Critical Care Associates
Rhode Island Department of Health
Vanderbilt University
Vermont Department of Health
Wake Forest University
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