Lance Chilton, M.D.
Professor, Pediatrics
University 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 VACCINEPREVENTABLE DISEASE?
A: INFLUENZA
AKA: “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
54,343
2,805
195,776
142
43
21,282
Hospitalized
Deaths
Molinari et al. Vaccine 25 (2007) 5086–5096
INFLUENZA DEATHS IN CHILDREN
NEW MEXICO’S SCHOOL KIDS’ INFLUENZA IMMUNIZATION PROJECT
X X XX
X
X
X
X
X
X
X
X
X
X
X X
X
X
X
X
X
XX
X X
X
X
X
X
X
X
X
X
X
X
X
XX
XX
X
X
X
X
X
XX
X
X
X
X
X
KUDOS TO SKIIP AND TO ALL OF YOU!
Flu Vaccine in Kids
80
60
US
New Mexico
40
20
0
Age 5-12
All Under 17
0
100
200
300
400
500
EARLY ALBUQUERQUE DATA: FLU  SCHOOL ABSENCES
0
10
20
30
40
50
week
week_Full_Day_IL
total_flu
week_Half_Day_IL
Gurule, Escareno, Dharas, Pentler, Skipper and Chilton, unpublished
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
Podium
Screen for Powerpoints
Head Table
M
L
Audience
ACIP
Members
Liaisons
Audience
M
L
Audience
ACIP Products
www.cdc.gov/vaccines
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?
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:
Streptococcal Infection =
Antigens:
25-50 antigens
Rotavirus
5
Pediarix
 Diphtheria
 Tetanus
 Pertussis
 Polio
 Hepatitis B
1
1
3
3
1
H. Influenzae B
1
Pneumococcal
13
Total
28
In the old days:
Smallpox vaccine =
~200 antigens
Upper respiratory
infection =
4-10 antigens
Whole cell pertussis
vaccine =
~3000 antigens
DECLINING NUMBER OF ANTIGENS:
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…
NEW MEXICO!)
For all children and
adolescents before
their 19th birthday
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!
WHY IS THIS IMPORTANT?
Vaccines for the first five years
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
April 1, 2014, CDC data
Vaccines for adolescence
Vaccine
Doses
Total
Gardasil
3
$425
Menactra 2
$226
Tdap
$38
TOTAL
1
$689
Vaccine Total Cost per Child
$2171
plus Influenza Vaccine,
$8-23/dose
IS IT WORTH IT? FIGURES FOR ONE BIRTH
COHORT – 2009: 4.26 MILLION BIRTHS
Disease
Cost:benefit ratio
Direct costs only:
3.0
Total societal
costs: 10.1
Deaths
Prevented
Cases 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
Pneumococcusrelated diseasesb
2 323 952
5056
965
2696
Rota
1 582 940
19
327
595
Total
19 685 495
42 032
20 267
76 360
DEATHS
THAT’S $20 BILLION and $76 BILLION!
Zhou F et al. Economic Evaluation of the Routine Childhood Immunization
Program in the US, 2009. Pediatrics, 2014. 133:577.
RESULTS…
VFC
VACCINE
VACCINE
for everyone
else
$90,000
THIS IS WHY WE DO IT…
Disease
Annual Cases
– Pre-Vaccine
Era
Annual Cases
Since Vaccine
Percent
Reduction
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%
HOW’RE WE DOING ON
INDIVIDUAL ADOLESCENT VACCINES?
90
80
70
60
50
40
30
20
10
0
90
80
70
60
50
40
30
20
10
UK
HOW DO THEY DO THAT?
NM
Vaccines for ChildrenUS
for
everyone in New Mexico is
under attack!
?
CDC 2012 NIS data in MMWR, Aug. 30, 2013
CERVICAL CANCER IN NEW MEXICO
New Mexico Tumor Registry, 2006-2010 data
Incidence
Race/Ethnicity
Age-adjusted rate
Average number of new
cases
Percent of all new
cases
Rank among all new cancer
cases†
NM, Non-Hispanic White
6.5
32
1.3%
13
NM, Hispanic
NM, American Indian
NM, Black
NM, All Races Combined
9.0
6.5
5.2
*
35
6
1
76
2.8%
2.7%
2.0%
1.9%
10
13
11
*
US, All Races Combined§
7.4
11,070
1.6%
13
Mortality
Race/Ethnicity
Age-adjusted
rate
Average number
of cancer deaths
Percent of all
cancer deaths
Rank among all cancer
deaths†
NM, Non-Hispanic White
1.7
10
1.1%
15
NM, Hispanic
NM, American Indian
NM, Black
NM, All Races Combined
3.1
3.5
*
12
3
-
2.6%
3.5%
-
12
10
-
26
1.7%
*
US, All Races Combined§
2.4
3,870
1.4%
14
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.
H P V V A C C I N AT I O N D O E S N O T C A U S E
T E E N AG E R S TO H AV E S E X
Mayhew A et al. Sexual Behaviors after HPV Vaccination. Pediatrics, 2014. 133:404.
SHOULD WE GIVE MORE VACCINES IN
NEW MEXICO SCHOOLS?
Yes
No
• That’s where the
• School nurses
kids are!
already have too
many tasks
• We could teach
about the
• Some vaccines
diseases
are too
prevented
controversial
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