Perspectives in Disease Prevention and Health Promotion Progress Toward Achieving the National 1990 Objectives for Immunization

The 1990 health objectives for the nation included 18 objectives on immunization (1). This update reports on progress toward achievement of these objectives through 1987.

IMPROVED HEALTH STATUS The first eight objectives cite the morbidity reduction targeted for eight diseases by 1990 (Table 1).

The targets for diphtheria and poliomyelitis appear to have been met, and substantial progress toward the targets for tetanus, rubella, and congenital rubella syndrome has been achieved. Morbidity from mumps had been declining until 1986, when the incidence of mumps increased 161% (2). The 12,848 cases reported in 1987 are the most since 1979. This increase largely reflected outbreaks in high schools and colleges and probably resulted from the absence or lack of enforcement of school immunization requirements in some states (2-4). Illinois and Tennessee had the highest mumps incidence rates in 1986 and 1987; these two states began enforcing comprehensive school laws requiring mumps vaccination in September 1987 and September 1988, respectively. During the first 26 weeks of 1988, 2945 cases were reported in the United States, representing a 69% decrease from the same period in 1987.

Between 1981 and 1987, the number of reported measles cases stabilized, with slightly more than 3000 average annual cases (range: 1497 cases in 1983 to 6282 cases in 1986). Outbreaks have occurred among both preschool-aged children, many of whom were unvaccinated, and high school- and college-aged persons, many of whom had been vaccinated. In many recent outbreaks, persons who received measles vaccine at 12-14 months of age have been at higher risk for measles than those vaccinated at greater than or equal to15 months of age (5). Intervention strategies to eliminate measles continue to be evaluated (6).

Improved surveillance indicates that pertussis also occurs in adolescents and adults as well as in infants and young children, although the illness is milder in these older persons (7). Increases in reported cases in 1985 and 1986 may be due to improved diagnosis and surveillance since diphtheria-tetanus-pertussis vaccine coverage in children does not appear to have declined.

IMPROVED SERVICES AND PROTECTION By 1990, at least 90% of all children by age 2 should have completed their immunization series--measles, mumps, rubella, polio, diphtheria, pertussis, and tetanus.

Although evaluation of progress toward this objective is difficult because of limited base-line data, it appears likely that this objective will not be met. In 1979, an estimated 70%-80% of 2-year-old children had received their basic immunization series. In the most recent U.S. Immunization Survey in 1985, 77% of 2-year-olds whose parents had records at home had received their basic series. Recent outbreaks of measles among unimmunized preschoolers also have shown that inadequate immunization levels still occur. To ensure that infants begin and complete their immunization series on schedule, efforts to develop recall and outreach systems must be continued.

By 1990, at least 95% of children attending licensed day-care facilities and kindergarten through 12th grade should be fully immunized.

Although national data are not available for children beyond the first grade, extrapolation of school entry data since 1980 suggests that this objective will be met. For the 1986-87 school year, immunization levels in licensed day-care facilities exceeded 90%. Of children entering kindergarten or first grade, 97% had been immunized.

By 1990, at least 60% of high-risk populations, as defined by the Immunization Practices Advisory Committee (ACIP) of the Public Health Service, should be receiving annual immunization against influenza.

This objective is unlikely to be met unless efforts are substantially intensified. The 1985 U.S. Immunization Survey indicates that only approximately 20% of high-risk persons received influenza vaccine during the preceding year.

INCREASED PUBLIC AND PROFESSIONAL AWARENESS By 1990, all mothers of newborns should receive instruction on immunization schedules for their babies before leaving the hospital or after home births.

This objective will probably be met because substantial progress has been made in educating mothers of newborns about immunizations. As of 1986, 39 of 52 jurisdictions (50 states, the District of Columbia, and New York City) had hospital- based maternal education programs in at least 90% of targeted hospitals.

IMPROVED SURVEILLANCE AND EVALUATION By 1990, at least 95% of all children 18 years of age and under should have up-to-date official immunization records in a uniform format using common guidelines for completion of immunization.

Standardized immunization records are now available in all states. Given the likelihood of achieving immunization level targets, this objective probably will be met. Although all states recommend the same immunization series, school immunization requirements vary from state to state. Consequently, the definition of "complete series" may vary.

By 1990, surveillance systems should be sufficiently improved that (1) at least 90% of those hospitalized and 50% of those not hospitalized with vaccine-preventable diseases of childhood are reported and (2) uniform case definitions are used nationwide.

Meeting the target for hospitalized persons may be feasible, but it is less likely that the target for persons who are not hospitalized can be met. The completeness of reporting varies by disease. Most cases of poliomyelitis, tetanus, and diphtheria are probably diagnosed, and nearly all are reported. As a result of the measles elimination initiative, measles reporting is now considered to be nearly complete. However, because of the variability in clinical manifestations of rubella, mumps, and pertussis, reporting of these diseases is probably incomplete. An estimated 22% of confirmed and compatible cases of congenital rubella syndrome diagnosed during the neonatal period are reported (8).

Uniform case definitions exist for measles, mumps, rubella, congenital rubella syndrome, poliomyelitis, diphtheria, tetanus, pertussis, and Haemophilus influenzae type b.

By 1990, at least 60% of high-risk populations, as defined by the ACIP, should have received vaccination against pneumococcal pneumonia.

The 1985 U.S. Immunization Survey indicates that approximately 10% of high-risk persons had received pneumococcal polysaccharide vaccine. Although administration of this vaccine is reimbursed under Medicare, this objective is unlikely to be met.

By 1990, at least 50% of people in populations designated as targets by the ACIP should be immunized within 5 years of licensure of new vaccines for routine clinical use.

Recently licensed vaccines include hepatitis B vaccine (licensed in 1982), Haemophilus influenzae type b polysaccharide vaccine (HbPV, licensed in 1985), and Haemophilus influenzae type b conjugate vaccine (HbCV, licensed in 1987). Hepatitis B vaccine is recommended for persons who are at risk of contact with blood or blood products (primarily health-care workers), homosexual men, household contacts of carriers of hepatitis B surface antigen, and users of illicit injectable drugs. Since data suggest that coverage for high-risk groups varies from 2% to 50%, this objective may be met in some target groups. HbCV is recommended for all children at 18 months of age and will likely replace most use of HbPV in 1988. Evaluating progress toward the objective for HbCV is not possible because of a lack of national data concerning coverage with this vaccine.

By 1990, no comprehensive health insurance policies should exclude immunizations.

Comprehensive data about insurance coverage of immunizations are not available. However, approximately 20 million persons are receiving services from health maintenance organizations that provide both preventive and treatment services. Medicaid provides reimbursement for childhood vaccines, and Medicare provides reimbursement for pneumococcal polysaccharide vaccine. In 1987, Congress authorized the Health Care Financing Administration to conduct a cost-effectiveness study beginning during the 1988-89 influenza season to determine whether influenza vaccine should be covered under Medicare.

By 1985, the nation should have a plan in place to mount mass immunization programs in the face of possible epidemics of influenza or other epidemic diseases for which vaccines may exist.

This objective has been met. Reported by: Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, Public Health Svc. Center for Biologics Evaluation and Review, Food and Drug Administration. Microbiology and Infectious Diseases Program, National Institute of Allergy and Infectious Diseases, National Institutes of Health. Div of Viral Diseases and Div of Bacterial Diseases, Center for Infectious Diseases; Div of Immunization, Center for Prevention Svcs, CDC.

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