The role of measles elimination in development of a national immunization program

A paired measles-rubella catch-up campaign in Sichuan China to stop an outbreak and strengthen local immunization programs

BACKGROUND

China has been working towards measles elimination, but in 2017, measles outbreaks occurred in Ganzi and Aba prefectures of Sichuan province, representing 95% of all provincial cases and jeopardizing measles elimination.

METHODS

During March and April 2017, high-performing prefectures were paired with outbreak and other interested counties to jointly conduct a measles-rubella (MR) catch-up campaign, build population immunity, and strengthen the counties' programs.

RESULTS

House-to-house search identified 88,383 children in Ganzi that lacked MCV vaccination; 85,144 (96.34%) were vaccinated. Search identified 33,683 children in Aba who were not vaccinated against measles; 33,074 (98.19%) were vaccinated. The supporting prefectures helped install Immunization Information Systems and enroll unvaccinated children into the immunization program.The outbreak ended within a month and incidence has remained low for the subsequent six years.

CONCLUSION

A paired catch-up campaign represents an effective model of using measles elimination strategies to strengthen local immunization programs for long-term program effectiveness.

Childhood Vaccination Practices and Parental Hesitancy Barriers in Rural and Urban Primary Care Settings

The purpose of our study was to identify primary care providers' (PCPs') practices in promoting childhood vaccination and their perceptions regarding barriers to vaccination in a primarily rural state. In January-May 2022, we conducted a mail and online survey of PCPs across Montana (n = 829). The survey included modules on routine immunizations in children 0-2 years old and COVID-19 vaccination in children 5-17 years old. The survey response rate was 36% (298/829). We categorized PCPs as working in rural (n = 218) or urban areas (n = 80), based on Rural-Urban Commuting Area codes. We then compared responses between rural and urban PCPs using chi-square tests. Urban PCPs (90-94%, depending on vaccine) stocked routinely recommended vaccines more frequently than rural PCPs (71-84%), but stocked the COVID-19 vaccine less often than rural PCPs (44% vs. 71%, respectively, p < 0.001). A higher percentage of rural providers reported parental beliefs that vaccine-preventable diseases are not severe enough to warrant vaccination (48% vs. 31%, p = 0.01) and concerns that vaccination will weaken their child's immune system (29% vs. 6%, p < 0.001). More rural (74%) compared to urban (59%) PCPs identified a social media campaign from local health departments promoting early childhood vaccinations as an effective strategy to increase childhood vaccination rates (p = 0.01). We identified key differences in some childhood vaccination practices and barriers between rural and urban PCPs. Interventions to increase rural vaccination rates could include increasing the number of providers stocking all recommended vaccines, identifying strategies to address parents' concerns regarding vaccine necessity, and collaborations with public health departments.

Gender differences in measles incidence rates in a multi-year, pooled analysis, based on national data from seven high income countries

Background

Gender differences in a number of infectious diseases have been reported. The evidence for gender differences in clinical measles incidence rates has been variable and poorly documented over age groups, countries and time periods.

Methods

We obtained data on cases of measles by sex and age group over a period of 11–27 years from seven countries. Male to female incidence rate ratios (IRR) were computed for each year, by country and age group. For each age group, we used meta-analytic methods to combine the IRRs. Meta-regression was conducted to the estimate the effects of age, country, and time period on the IRR.

Results

In the age groups < 1, 1–4, 5–9, 10–14, 15–44, and 45–64 the pooled IRRs (with 95% CI) were 1.07 (1.02–1.11), 1.10 (1.07–1.14), 1.03 (1.00–1.05), 1.05 (0.99–1.11), 1.08 (0.95–1.23), and 0.82 (0.74–0.92) respectively. The excess incidence rates (IR) from measles in males up to age 45 are remarkably consistent across countries and time-periods. In the age group 45–64, there is an excess incidence in women.

Conclusions

The consistency of the excess incidence rates in young males suggest that the sex differences are more likely due to physiological and biological differences and not behavioral factors. At older ages, differential exposure can play a part. These findings can provide further keys to the understanding of mechanisms of infection and tailoring vaccination schedules.

Considering a COVID-19 vaccine mandate for pediatric kidney transplant candidates

The world continues to face the effects of the SARS-CoV-2 pandemic. COVID-19 vaccines are safe and effective in protecting recipients, decreasing the risk of COVID-19 acquisition, transmission, hospitalization, and death. Transplant recipients may be at greater risk for severe SARS-CoV-2 infection. As a result, transplant programs have begun instituting mandates for COVID-19 vaccine for transplant candidacy. While the question of mandating COVID-19 vaccine for adult transplant candidates has garnered attention in the lay and academic press, these discussions have not explicitly addressed children who may be otherwise eligible for kidney transplants. In this paper we seek to examine the potential ethical justifications of a COVID-19 vaccine mandate for pediatric kidney transplant candidacy through an examination of relevant ethical principles, analogous cases of the use of mandates, differences between adult and pediatric kidney transplant candidates, and the role of gatekeeping in transplant vaccine mandates. At present, it does not appear that pediatric kidney transplant centers are justified to institute a COVID-19 vaccine mandate for candidates. Finally, we will offer suggestions to be considered prior to the implementation of a COVID-19 vaccine mandate.

When measles came to class: a look back at the 1989 Kent State University measles epidemic

BACKGROUND

Measles was eliminated from the United States in 2000, following a change from a single dose of measles vaccine to two doses after an epidemic 1989-1991. Several college campuses experienced outbreaks, including Kent State University (KSU) in Ohio.

METHODS

Local news media from 1988-1989 were searched in August 2019. Interventions taken by the university were recorded, and an epidemic curve constructed.

RESULTS

The first measles cases were reported in October 1988. The outbreak diminished over winter break. New cases were confirmed in February 1989. Infected students were instructed to vacate the dorms. Vaccines were mandated for student groups. The epidemic grew rapidly in March but slowed after spring break. By April, 380 cases had been reported and 7000 students vaccinated.

CONCLUSIONS

KSU was one of the hardest-hit universities during the 1989 measles epidemic. A combination of vaccination, isolation, quarantine, and elimination of public events helped to curtail the epidemic.

Global trends in measles publications

INTRODUCTION

Beginning with the 1960s, this review analyzes trends in publications on measles indexed by the National Library of Medicine from January 1960 to mid-2018. It notes both the growth in numbers of published papers, and the increasing number and proportion of publications, in the current century, of articles on such items as costing, measles elimination, and determinants of coverage.

METHODS

A two-person team extracted from the National Library of Medicine (NLM) homepage all citations on measles beginning in 1960 and continuing through mid-2018. These were then classified both by overall number and by subject matter, with tabular summaries of both by decade and by subject matter. The tabular presentation forms the basis for a discussion of the ten most frequently cited subjects, and publication trends, with a special emphasis on the current century.

RESULTS

As in the past, the most often currently published items have been on coverage and its determinants, measles elimination, outbreak reports, SSPE, and SIAs. The putative relationship between vaccination and autism saw a spurt of articles in the 1990s, rapidly declining after the IOM report rejecting the causative hypothesis.

CONCLUSION

There is a discussion on the sequencing of polio and measles eradication, the former unlikely before 2022, and an examination of likely research priorities as the world moves from measles control to measles eradication. There is a key role for social science in combatting vaccination reticence. The role of technical innovations, such as micropatch vaccination, is discussed.

Turning up the heat: Effect of new vaccine for children's (VFC) program recommendations for use of temperature monitors upon incorrect product storage adverse event reporting

BACKGROUND

The Centers for Disease Control and Prevention (CDC) coordinates the Vaccines For Children (VFC) program, which provides free vaccines to qualified children in the US. In 2009, the CDC issued Vaccine Storage Requirements, which were later replaced (2012) with an interim guidance and toolkit for vaccine storage and handling. The guidance called for use of Digital Data Loggers (DDL) to monitor vaccine storage temperatures. We describe a change in frequency of Incorrect Product Storage Reports (IPSRs) following issuance of the 2009 CDC guidance.

METHODS

Merck & Co., Inc., Kenilworth, NJ, USA, systematically evaluates vaccine safety concerns for all products. The safety database was queried (01-Jan-2004 through 31-December-2016) to identify all IPSRs associated with 10 vaccines. We compared IPSRs received prior to and following the 2009 CDC guidance, comparing reports received from the US with those received from international sources during the same period.

RESULTS

Following the release of the DDL guidance, a progressive increase in IPSRs was identified in the US (1 report received in 2004, 12,993 reports in 2016). In contrast, non-US IPSRs - have not had a similar increase: no reports received in 2004, 216 reports received in 2016. US reports of IPSRs 2004 through 2016 account for 96% of reports worldwide. There were no serious reports found in the database in conjunction with IPSRs, nor were there any additional safety findings in any of the reports with additional events reported.

CONCLUSION

VFC DDL guidance was followed by an increase in IPSRs. No similar trend was seen outside the US (where no broad change in DDL guidance occurred). Despite the increase in IPSRs, there have been few associated adverse events (AEs) reported; no new safety concerns were identified. These findings suggest that the increase in IPSRs was associated with the introduction of use of DDLs, and suggests the need for further impact assessment.

Measles and Rubella Global Strategic Plan 2012-2020 midterm review report: Background and summary

Measles, a vaccine-preventable illness, is one of the most infectious diseases known to man. In 2015, an estimated 134,200 measles deaths occurred globally. Rubella, also vaccine-preventable, is a concern because infection during pregnancy can result in congenital defects in the baby. More than 100,000 babies with congenital rubella syndrome were estimated to have been born globally in 2010. Eradication of both measles and rubella is considered to be feasible, beneficial, and more cost-effective than high-level control. All six World Health Organization (WHO) regions have measles elimination goals by 2020 and two have rubella elimination goals by that year. However, the World Health Assembly has not endorsed a global eradication goal for either disease. In 2012, the Measles and Rubella Initiative published a Global Measles and Rubella Strategic Plan, 2012-2020, referred to hereafter as the Plan, which aimed to achieve measles and rubella elimination in at least five WHO regions by end-2020 through the implementation of five core strategies, with progress evaluated against 2015 milestones. When, by end-2015, none of these milestones had been met, WHO's Strategic Advisory Group of Experts on Immunization (SAGE) recommended a mid-term review of the Plan to evaluate progress toward goals, assess the quality of strategy implementation, and formulate lessons learned. A five-member team reviewed documents and conducted interviews with stakeholders as the basis for the review's conclusions and recommendations. This team concluded that, although significant progress in measles elimination had been made, progress had slowed. It recommended that countries continue to work toward elimination goals with a focus on strengthening ongoing immunization systems. In addition, it concluded that the strategies articulated in the Plan were sound, however full implementation had been impeded by inadequate country ownership and global political will, reflected in inadequate resources. Detailed recommendations for each of the Plan's five strategies as well as the areas of polio transition, governance and resource mobilization are outlined.

Measles and rubella elimination: learning from polio eradication and moving forward with a diagonal approach

INTRODUCTION

In 1988, an estimated 350,000 children were paralyzed by polio and 125 countries reported polio cases, the World Health Assembly passed a resolution to achieve polio eradication by 2000, and the Global Polio Eradication Initiative (GPEI) was established as a partnership focused on eradication. Today, following eradication efforts, polio cases have decreased >99% and eradication of all three types of wild polioviruses is approaching. However, since polio resources substantially support disease surveillance and other health programs, losing polio assets could reverse progress toward achieving Global Vaccine Action Plan goals. Areas covered: As the end of polio approaches and GPEI funds and capacity decrease, we document knowledge, experience, and lessons learned from 30 years of polio eradication. Expert commentary: Transitioning polio assets to measles and rubella (MR) elimination efforts would accelerate progress toward global vaccination coverage and equity. MR elimination feasibility and benefits have long been established. Focusing efforts on MR elimination after achieving polio eradication would make a permanent impact on reducing child mortality but should be done through a 'diagonal approach' of using measles disease transmission to identify areas possibly susceptible to other vaccine-preventable diseases and to strengthen the overall immunization and health systems to achieve disease-specific goals.

Vaccine exemptions and the kindergarten vaccination coverage gap

BACKGROUND

Vaccination requirements for kindergarten entry vary by state, but all states require 2 doses of measles containing vaccine (MCV) at kindergarten entry.

OBJECTIVE

To assess (i) national MCV vaccination coverage for children who had attended kindergarten; (ii) the extent to which undervaccination after kindergarten entry is attributable to parents' requests for an exemption; (iii) the extent to which undervaccinated children had missed opportunities to be administered missing vaccine doses among children whose parent did not request an exemption; and (iv) the vaccination coverage gap between the "highest achievable" MCV coverage and actual MCV coverage among children who had attended kindergarten.

METHODS

A national survey of 1465 parents of 5-7year-old children was conducted during October 2013 through March 2014. Vaccination coverage estimates are based provider-reported vaccination histories. Children have a "missed opportunity" for MCV if they were not up-to-date and if there were dates on which other vaccines were administered but not MCV. The "highest achievable" MCV vaccination coverage rate is 100% minus the sum of the percentages of (i) undervaccinated children with parents who requested an exemption; and (ii) undervaccinated children with parents who did not request an exemption and whose vaccination statuses were assessed during a kindergarten grace period or period when they were provisionally enrolled in kindergarten.

RESULTS

Among all children undervaccinated for MCV, 2.7% were attributable to having a parent who requested an exemption. Among children who were undervaccinated for MCV and whose parent did not request an exemption, 41.6% had a missed opportunity for MCV. The highest achievable MCV coverage was 98.6%, actual MCV coverage was 90.9%, and the kindergarten vaccination gap was 7.7%.

CONCLUSION

Vaccination coverage may be increased by schools fully implementing state kindergarten vaccination laws, and by providers assessing children's vaccination status at every clinic visit, and administering missed vaccine doses.

Measles in the United States since the Millennium: Perils and Progress in the Postelimination Era

This article describes measles and measles vaccination, along with the challenges, successes, and progress in the postelimination era.

Transitioning Lessons Learned and Assets of the Global Polio Eradication Initiative to Global and Regional Measles and Rubella Elimination

The Global Polio Eradication Initiative has built an extensive infrastructure with capabilities and resources that should be transitioned to measles and rubella elimination efforts. Measles continues to be a major cause of child mortality globally, and rubella continues to be the leading infectious cause of birth defects. Measles and rubella eradication is feasible and cost saving. The obvious similarities in strategies between polio elimination and measles and rubella elimination include the use of an extensive surveillance and laboratory network, outbreak preparedness and response, extensive communications and social mobilization networks, and the need for periodic supplementary immunization activities. Polio staff and resources are already connected with those of measles and rubella, and transitioning existing capabilities to measles and rubella elimination efforts allows for optimized use of resources and the best opportunity to incorporate important lessons learned from polio eradication, and polio resources are concentrated in the countries with the highest burden of measles and rubella. Measles and rubella elimination strategies rely heavily on achieving and maintaining high vaccination coverage through the routine immunization activity infrastructure, thus creating synergies with immunization systems approaches, in what is termed a "diagonal approach."

Modeling the Transmission of Measles and Rubella to Support Global Management Policy Analyses and Eradication Investment Cases

Policy makers responsible for managing measles and rubella immunization programs currently use a wide range of different vaccines formulations and immunization schedules. With endemic measles and rubella transmission interrupted in the region of the Americas, all five other regions of the World Health Organization (WHO) targeting the elimination of measles transmission by 2020, and increasing adoption of rubella vaccine globally, integrated dynamic disease, risk, decision, and economic models can help national, regional, and global health leaders manage measles and rubella population immunity. Despite hundreds of publications describing models for measles or rubella and decades of use of vaccines that contain both antigens (e.g., measles, mumps, and rubella vaccine or MMR), no transmission models for measles and rubella exist to support global policy analyses. We describe the development of a dynamic disease model for measles and rubella transmission, which we apply to 180 WHO member states and three other areas (Puerto Rico, Hong Kong, and Macao) representing >99.5% of the global population in 2013. The model accounts for seasonality, age-heterogeneous mixing, and the potential existence of preferentially mixing undervaccinated subpopulations, which create heterogeneity in immunization coverage that impacts transmission. Using our transmission model with the best available information about routine, supplemental, and outbreak response immunization, we characterize the complex transmission dynamics for measles and rubella historically to compare the results with available incidence and serological data. We show the results from several countries that represent diverse epidemiological situations to demonstrate the performance of the model. The model suggests relatively high measles and rubella control costs of approximately $3 billion annually for vaccination based on 2013 estimates, but still leads to approximately 17 million disability-adjusted life years lost with associated costs for treatment, home care, and productivity loss costs of approximately $4, $3, and $47 billion annually, respectively. Combined with vaccination and other financial cost estimates, our estimates imply that the eradication of measles and rubella could save at least $10 billion per year, even without considering the benefits of preventing lost productivity and potential savings from reductions in vaccination. The model should provide a useful tool for exploring the health and economic outcomes of prospective opportunities to manage measles and rubella. Improving the quality of data available to support decision making and modeling should represent a priority as countries work toward measles and rubella goals.

Improving the Science of Measles Prevention-Will It Make for a Better Immunization Program?

In a Perspective, Julie Garon and Walter Orenstein discuss Lessler and colleagues' modeling study on measles vaccination and the implications for triggered and routine immunization programs.

Lessons Learned From Making and Implementing Vaccine Recommendations in the U.S

After publication of certain vaccine recommendations made by the Advisory Committee on Immunization Practices, several unexpected events have occurred during implementation of these recommendations. These have included changes in recommendations following adverse events involved with a particular vaccine and the conferral of community protection as an offshoot of vaccination of a specific population. Vaccine shortages and hesitancy have also been proven impediments to full implementation, and vaccine recommendations have not gone unaffected by either public perception of a vaccine or by cost considerations.

Hope: a new approach to understanding structural factors in HIV acquisition

This paper presents the first empirical results of a long-term project exploring the use of hope as a concept summarising people's experience of the social, economic and cultural world they inhabit. The work has its roots in attempts to understand socio-economic aspects of HIV/AIDS epidemiology through recourse to the term 'structural drivers'. In this paper, we recognise the distinguished contribution made by that body of work but adopt a different theoretical approach, one based on the idea of emergent social properties. This is an idea derived from the Durkheim's notion of a 'social current'. One such emergent property is hope and its potential use and applicability as an epidemiological variable is described. The variable is measured using the Snyder scale developed by the late Rick Snyder for quite other purposes in the USA. We use data from the long-standing UK MRC/UVRI General Cohort Study in Uganda together with a smaller study of some fishing communities. The results show that the Snyder scale (1) does measure a real variable, (2) does mean something to Ugandan rural populations and (3) can be used to explore some known risk factors for HIV acquisition.

Measles vaccine coverage estimates in an outbreak three years after the nation-wide campaign in China: implications for measles elimination, 2013

Background

China is approaching measles elimination, but indigenous measles still circulates. County L in China has reported measles-containing vaccine (MCV) coverage rates >95% since 2000. Despite high reported coverage, a large measles outbreak occurred among young children in L County. We measured MCV coverage using 5 different methods during an investigation on this outbreak and compared our estimates with reported rates.

Methods

Reported coverage rates are determined by aggregating clinic-based data across the county: doses administered in each clinic divided by the number of children registered in each clinic. Our methods estimated coverage for the 2010–2012 birth cohort, and were (1) administrative method: doses administered in clinics divided by the birth cohort recorded in the Statistical Year Book, (2) house-to-house convenience-sample survey of children living near cases, (3) vaccination clinic records review, (4) determination of a convenience sample of measles outbreak cases’ vaccination statuses and using the field vaccine efficacy outbreak equation to estimate population coverage, and (5) a seroprevalence survey using a convenience sample of residual blood samples from hospitals.

Results

The measles outbreak totaled 215 cases, representing an incidence of 195.8 per million population. Our estimated MCV coverage rates were: (1) administrative method: 84.1%-87.0% for MCV1 and 80.3%-90.0% for MCV2, (2) in-house survey: 83.3% of 9–17 month children received MCV1, and 74.5% of 24–47 month children received MCV2, (3) clinic record review: 85.5% of 9–17 month children received MCV1, and 73.2% of 24–59 month children received MCV2, (4) field VE method: 83.6% of 9–47 month children received one or more MCV doses, and (5) serology: seropositive rates were <80% in the 12–17 and 18–23 month age cohorts.

Conclusions

Compared with reported coverage >95%, our 5 coverage assessments all showed substantially lower coverage. China should evaluate guidelines for reporting vaccination coverage and identify feasible improvements to the assessment methods.

The history of the United States Advisory Committee on Immunization Practices (ACIP)

The United States Advisory Committee on Immunization Practices (ACIP) is a federal advisory committee that develops written recommendations for use of vaccines licensed by the Food and Drug Administration (FDA) for the U.S. civilian population. Vaccine development and disease outbreaks contributed to the need for a systematized, science-based, formal mechanism for establishing national immunization policy in this country. Formed in 1964, the ACIP was charged with this role. The committee has undergone significant changes in structure and operational activities during its 50-year history. The ACIP works closely with many liaison organizations to develop its immunization recommendations, which are harmonized among key professional medical societies. ACIP vaccine recommendations form two immunization schedules, which are updated annually: (1) the childhood and adolescent immunization schedule and (2) the adult immunization schedule. Today, once ACIP recommendations are adopted by the Director of the Centers for Disease Control and Prevention and the Secretary of the Department of Health and Human Services, these recommendations are published in Morbidity and Mortality Weekly Report (MMWR), become official policy, and are incorporated into the appropriate immunization schedule.

Enabling implementation of the Global Vaccine Action Plan: developing investment cases to achieve targets for measles and rubella prevention

Global prevention and control of infectious diseases requires significant investment of financial and human resources and well-functioning leadership and management structures. The reality of competing demands for limited resources leads to trade-offs and questions about the relative value of specific investments. Developing investment cases can help to provide stakeholders with information about the benefits, costs, and risks associated with available options, including examination of social, political, governance, and ethical issues. We describe the process of developing investment cases for globally coordinated management of action plans for measles and rubella as tools for enabling the implementation of the Global Vaccine Action Plan (GVAP). We focus on considerations related to the timing of efforts to achieve measles and rubella goals independently and within the context of ongoing polio eradication efforts, other immunization priorities, and other efforts to control communicable diseases or child survival initiatives. Our analysis suggests that the interactions between the availability and sustainability of financial support, sufficient supplies of vaccines, capacity of vaccine delivery systems, and commitments at all levels will impact the feasibility and timing of achieving national, regional, and global goals. The timing of investments and achievements will determine the net financial and health benefits obtained. The methodology, framing, and assumptions used to characterize net benefits and uncertainties in the investment cases will impact estimates and perceptions about the value of prevention achieved overall by the GVAP. We suggest that appropriately valuing the benefits of investments of measles and rubella prevention will require the use of integrated dynamic disease, economic, risk, and decision analytic models in combination with consideration of qualitative factors, and that synthesizing information in the form of investment cases may help stakeholders manage expectations as they chart the course ahead and navigate the decade of vaccines.

Monitoring progress towards the elimination of measles in China: an analysis of measles surveillance data

OBJECTIVE

To analyse the epidemiology of measles in China and determine the progress made towards the national elimination of the disease.

METHODS

We analysed measles surveillance data - on the age, sex, residence and vaccination status of each case and the corresponding outcome, dates of onset and report and laboratory results - collected between January 2005 and October 2013.

FINDINGS

Between 2005 and October 2013, 596 391 measles cases and 368 measles-related deaths were reported in China. Annual incidence, in cases per 100 000 population, decreased from 9.95 in 2008 to 0.46 in 2012 but then rose to more than 1.96 in 2013. The number of provinces that reported an annual incidence of less than one case per million population increased from one in 2009 to 15 in 2012 but fell back to one in 2013. Median case age decreased from 83 months in 2005 to 14 months in 2012 and 11 months in January to October 2013. Between 2008 and 2012, the incidence of measles in all age groups, including those not targeted for vaccination, decreased by at least 93.6%. However, resurgence started in late 2012 and continued into 2013. Of the cases reported in January to October 2013, 40% were aged 8 months to 6 years.

CONCLUSION

Although there is evidence of progress towards the elimination of measles from China, resurgence in 2013 indicated that many children were still not being vaccinated on time. Routine immunization must be strengthened and the remaining immunity gaps need to be identified and filled.

Think globally, act locally: the role of local demographics and vaccination coverage in the dynamic response of measles infection to control

The global reduction of the burden of morbidity and mortality owing to measles has been a major triumph of public health. However, the continued persistence of measles infection probably not only reflects local variation in progress towards vaccination target goals, but may also reflect local variation in dynamic processes of transmission, susceptible replenishment through births and stochastic local extinction. Dynamic models predict that vaccination should increase the mean age of infection and increase inter-annual variability in incidence. Through a comparative approach, we assess national-level patterns in the mean age of infection and measles persistence. We find that while the classic predictions do hold in general, the impact of vaccination on the age distribution of cases and stochastic fadeout are mediated by local birth rate. Thus, broad-scale vaccine coverage goals are unlikely to have the same impact on the interruption of measles transmission in all demographic settings. Indeed, these results suggest that the achievement of further measles reduction or elimination goals is likely to require programmatic and vaccine coverage goals that are tailored to local demographic conditions.

Finding the proper balance between freedom and justice: why we should not eliminate personal belief exemptions to vaccine mandates

Lantos and colleagues (this issue) propose to eliminate personal belief exemptions from school vaccine mandates, particularly for those vaccines that target deadly contagious childhood disease. They argue that not doing so would be unjust. In this counterpoint, we argue that, for reasons grounded in both health policy and morality, a just vaccine policy need not prohibit parents from claiming personal belief exemptions.

Building on the success of the Expanded Programme on Immunization: enhancing the focus on disease prevention and control

The Expanded Programme on Immunization (EPI) has succeeded in establishing a vaccine delivery system in all low and middle income (LMI) countries. Because EPI has focused on immunization delivery, its major outcome is measured in many countries only as vaccine coverage, not as disease reduction, the real goal of EPI. Monitoring disease reduction requires real-time case-based disease surveillance and appropriate interventions, for which a functional public health infrastructure is needed. If the highest priority for assessing impact of EPI shifts to disease prevention and control from vaccine coverage, the programme may be transformed to one of control of childhood communicable diseases (CCCD), with the potential of expanding the range of diseases of children and adults for control and of integrating all other current vertical (single disease) control efforts with it. EPI provides the essential platform on which CCCD can be built to create a public health infrastructure.

Vaccination coverage among U.S. adolescents aged 13-17 years eligible for the Vaccines for Children program, 2009

OBJECTIVES

We compared (1) characteristics of adolescents who are and are not entitled to receive free vaccines from the Vaccines for Children (VFC) program and (2) vaccination coverage with meningococcal conjugate (MCV4), quadrivalent human papillomavirus (HPV4), and tetanus-diphtheria-acellular pertussis (Tdap) vaccines among VFC-eligible and non-VFC-eligible adolescents.

METHODS

We analyzed data from the 2009 National Immunization Survey-Teen, a nationally representative, random-digit-dialed survey of households with adolescents aged 13-17 years (n = 20,066). Differences in sociodemographic characteristics and provider-reported vaccination coverage were evaluated using t-tests.

RESULTS

Overall, 32.1% (+/- 1.2%) of adolescents were VFC-eligible. VFC-eligible adolescents were significantly less likely than non-VFC-eligible adolescents to be white and to live in suburban areas, and more likely to live in poverty and to have younger and less educated mothers. Nationally, coverage among non-VFC-eligible adolescents was 57.1% (+/-1.5%) for > or = 1 dose of Tdap, 55.4% (+/-1.5%) for > or = 1 dose of MCV4, and 43.2% (+/- 2.2%) for > or = 1 dose of HPV4. Coverage among VFC-eligible adolescents was 52.5% (+/- 2.4%) for > or = 1 dose of Tdap, 50.1% (+/- 2.4%) for > or = 1 dose of MCV4, and 46.6% (+/- 3.5%) for > or =1 dose of HPV4. Only 27.5% (+/- 1.8%) of non-VFC-eligible adolescents and 25.0% (+/- 2.9%) of VFC-eligible adolescents received > or = 3 doses of HPV4. Vaccination coverage was significantly higher among non-VFC-eligible adolescents for Tdap and MCV4, but not for one-dose or three-dose HPV4. Conclusions. Coverage with some recommended vaccines is lower among VFC-eligible adolescents compared with non-VFC-eligible adolescents. Continued monitoring of adolescent vaccination rates, particularly among VFC-eligible populations, is needed to ensure that all adolescents receive all routinely recommended vaccines.

The Measles Initiative: moving toward measles eradication

The World Health Assembly should establish a target date for measles eradication based on continued progress toward existing mortality reduction goals. We have a safe, effective, and inexpensive vaccine; a proven elimination strategy; high country demand; and an effective global partnership. Since it was founded in 2001, the Measles Initiative has supported the vaccination of >900 million children in supplementary immunization activities. Largely as a result, global measles deaths decreased by 78% between 2000 and 2008, averting an estimated 4.3 million deaths. The Measles Initiative has exceeded its targets and evolved to address increasingly ambitious goals. The current challenges include a decline in funding and weak routine immunization systems in some countries. Skeptics of measles eradication raise 3 main objections: the yet-to-be-achieved polio eradication goal, the high cost, and the impact on health systems. These are important concerns that can be addressed with judicious program planning. All 6 World Health Organization regions have committed to measles elimination, and 5 have set a target date. The World Health Assembly has endorsed interim targets toward eradication, and an independent global measles advisory group has determined measles can and should be eradicated. A target date for eradication will focus efforts and capitalize on the achievements of the last decade.

Antibodies to measles in individuals with recent onset psychosis

BACKGROUND

Measles virus is a highly prevalent neurotropic virus capable of causing persistent infections within the central nervous system.

METHODS

We measured IgG class antibodies to measles in 820 individuals including 138 with recent onset psychosis, 378 with persistent schizophrenia, and 304 non-psychiatric controls. Levels of antibodies among the groups were compared by bivariate and by multivariate analyses and correlated with clinical and demographic variables.

RESULTS

The level of measles antibodies in individuals with a recent onset of psychosis was greater than the level of antibodies in individuals with persistent schizophrenia or individuals without a history of a psychiatric disorder (p<.00001). The level of measles antibodies in the individuals with persistent schizophrenia was greater than the level of measles antibodies in the controls (p<.001). Recent onset of psychosis was associated with having elevated levels of measles antibodies, defined as the 90th percentile of the levels of the controls, with an odds ratio of 8.0 (95% CI 4.6, 14.0); persistent schizophrenia was associated with having this level with an odds ratio of 2.3 (95% CI 1.4, 3.7). Within the psychiatric groups, measles antibody levels were associated with age, race, and current treatment with the antipsychotic medication, olanzapine.

CONCLUSIONS

The reasons for elevated levels of measles antibodies in the psychiatric groups are not known with certainty and should be studied in prospective investigations.

Controversies in vaccine mandates

Policies that mandate immunization have always been controversial. The controversies take different forms in different contexts. For routine childhood immunizations, many parents have fears about both short- and long-term side effects. Parental worries change as the rate of vaccination in the community changes. When most children are vaccinated, parents worry more about side effects than they do about disease. Because of these worries, immunization rates go down. As immunization rates go down, disease rates go up, and parents worry less about side effects of vaccination and more about the complications of the diseases. Immunization rates then go up. For teenagers, controversies arise about the criteria that should guide policies that mandate, rather than merely recommend and encourage, certain immunizations. In particular, policy makers have questioned whether immunizations for human papillomavirus, or other diseases that are not contagious, should be required. For healthcare workers, debates have focused on the strength of institutional mandates. For years, experts have recommended that all healthcare workers be immunized against influenza. Immunizations for other infections including pertussis, measles, mumps, and hepatitis are encouraged but few hospitals have mandated such immunizations-instead, they rely on incentives and education. Pandemics present a different set of problems as people demand vaccines that are in short supply. These issues erupt into controversy on a regular basis. Physicians and policy makers must respond both in their individual practices and as advisory experts to national and state agencies. The articles in this volume will discuss the evolution of national immunization programs in these various settings. We will critically examine the role of vaccine mandates. We will discuss ways that practitioners and public health officials should deal with vaccine refusal. We will contrast responses of the population as a whole, within the healthcare setting, and in the setting of pandemic influenza.

Preventing cervical cancer : overviews of the National Breast and Cervical Cancer Early Detection Program and 2 US immunization programs

Three federal programs with the potential to reduce cervical cancer incidence, morbidity, and mortality, especially among underserved populations, are administered by the Centers for Disease Control and Prevention (CDC): the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), the Vaccines for Children (VFC) Program, and the Section 317 immunization grant program. The NBCCEDP provides breast and cervical cancer screening and diagnostic services to uninsured and underinsured women. The VFC program and the Section 317 immunization grant program provide vaccines, including human papillomavirus (HPV) vaccine, to targeted populations at no cost for these vaccines. This article describes the programs, their histories, populations served, services offered, and roles in preventing cervical cancer through HPV vaccination and cervical cancer screening. Potential long-term reduction in healthcare costs resulting from HPV vaccination is also discussed. As an example of an initiative to vaccinate uninsured women aged 19-26 years through a cancer services program, a state-based effort that was recently launched in New York, is highlighted.

Measles: old vaccines, new vaccines

Isolation of measles virus in tissue culture by Enders and colleagues in the 1960s led to the development of the first measles vaccines. An inactivated vaccine provided only short-term protection and induced poor T cell responses and antibody that did not undergo affinity maturation. The response to this vaccine primed for atypical measles, a more severe form of measles, and was withdrawn. A live attenuated virus vaccine has been highly successful in protection from measles and in elimination of endemic measles virus transmission with the use of two doses. This vaccine is administered by injection between 9 and 15 months of age. Measles control would be facilitated if infants could be immunized at a younger age, if the vaccine were thermostable, and if delivery did not require a needle and syringe. To these ends, new vaccines are under development using macaques as an animal model and various combinations of the H, F, and N viral proteins. Promising studies have been reported using DNA vaccines, subunit vaccines, and virus-vectored vaccines.