Current Trends Update: Childhood Vaccine-Preventable Diseases -- United States, 1994

In 1993, the Childhood Immunization Initiative (CII) established disease elimination goals for six childhood vaccine-preventable diseases. Specific goals for 1996 include elimination of indigenous transmission of measles, rubella (and congenital rubella syndrome {CRS}), poliomyelitis (polio) caused by wild poliovirus, and diphtheria in all age groups; elimination of tetanus in children aged less than 15 years; and elimination of invasive disease due to Haemophilus influenzae type b (Hib) in children aged less than 5 years. This report summarizes progress toward reaching these goals during January-August 1994, compares these findings with those from the same period during 1993, and provides information about mumps and pertussis -- diseases for which reduction goals will be established.

Based on provisional data for reporting of vaccine-preventable diseases to the National Notifiable Diseases Surveillance System (NNDSS), during January-August 1994, the occurrence of polio, diphtheria, tetanus, and CRS remain at or near the disease elimination goals. In comparison with 1993, NNDSS indicates a substantial increase in reported cases of measles, a less dramatic increase in reported cases of rubella, and decreases in reported cases of H. influenzae invasive disease, pertussis, and mumps.

Polio, diphtheria, and tetanus. No cases of indigenously transmitted wild poliovirus infection have been reported in the United States since 1979, and in September 1994, the International Commission for the Certification of Poliomyelitis Eradication in the Americas certified elimination of poliovirus from the Americas (1). One case of vaccine-associated polio in a 3-month old child has been confirmed in 1994. One case of diphtheria has been reported in 1994 in an unvaccinated 4-year-old boy in Massachusetts who died of diphtheria myocarditis; the child's parents were members of a religious group that does not routinely accept vaccination. During 1994, 22 cases of tetanus were reported; eight (40%) were in persons aged greater than or equal to 65 years, and none were in children aged less than 15 years.

Measles. During 1994, 814 cases of measles were provisionally reported to NNDSS. During the first 26 weeks of 1994, 15 measles outbreaks (clusters of five or more epidemiologically related cases) were reported by 10 states (2). However, only 18 cases were reported in August, as outbreak activity diminished. Of 808 cases in persons with known age, 185 (23%) were in persons aged less than 5 years, compared with 93 (38%) of 245 cases in persons with known age during 1993.

Rubella. During 1994, 204 cases of rubella were reported to NNDSS, compared with 157 cases during 1993. Of 200 cases in persons with known age, 19 (9%) were in persons aged less than 5 years, compared with 23 (16%) of 146 during 1993. Of all rubella cases reported in 1994, 59% have been associated with an extended outbreak among unvaccinated adults in Massachusetts. Two cases of CRS were reported during January-August 1994; both of these cases were delayed reports of CRS in infants born during 1992-1993. Of five cases of CRS reported during 1993, four were delayed reports for infants born in 1992.

H. influenzae invasive disease. Of 784 cases of invasive H. influenzae disease reported during 1994, age was reported for 746; of these, 210 (28%) were in persons aged less than 5 years, representing a 20% decrease in reported cases among this age group when compared with 1993. Because of incomplete reporting of serotype, the proportion of cases of H. influenzae invasive disease caused by type b organisms is unknown. However, based on active laboratory-based surveillance in four states, during 1993 invasive disease caused by Hib accounted for 27% of all H. influenzae invasive disease among children aged less than 5 years (3).

Pertussis. During 1994, a total of 2203 cases of pertussis were reported, compared with 3171 during 1993. No large (i.e., more than 50 cases) citywide or statewide outbreaks of disease have been reported to CDC in 1994. In contrast, in 1993 large outbreaks occurred in both Chicago and Cincinnati.

Mumps. During 1994, a total of 957 cases of mumps were reported -- a 15% decrease from 1993. Of 881 cases in persons with known age, 155 (18%) were in persons aged less than 5 years, the same proportion as in 1993. Reported by: National Immunization Program, CDC.

Editorial Note

Editorial Note: Although reported cases of most childhood vaccine-preventable diseases remain at or near all-time low levels, improved case reporting and disease-control efforts are necessary to achieve the disease-reduction goals of the CII (4). In particular, control of measles and rubella will require improved reporting of cases of rash illness with fever, rapid availability of confirmatory laboratory testing, and rapid implementation of outbreak-control measures. Ongoing efforts also must focus on achieving and maintaining high levels of vaccination coverage in preschool-aged children in all areas of the United States, and full implementation of the current recommendation of the Advisory Committee on Immunization Practices for a second dose of measles vaccine for school and college attendees. The continuing occurrence of measles and rubella among young adults highlights the need to ensure vaccination of such persons. Health-care providers should use every opportunity to vaccinate adolescents and young adults who do not have documented immunity against these diseases.

During the first 26 weeks of 1994, 45% of all persons with measles, and 166 (72%) of 230 persons with measles who had not received a measles-containing vaccine more than 14 days before onset of measles, reported a religious or philosophic exemption to vaccination (2). The continued occurrence of measles and other vaccine-preventable diseases among persons in these groups highlights the need for improved strategies for increasing the acceptance of vaccination and for prompt control measures when an outbreak occurs in these susceptible populations.

Although coverage with three or more doses of diphtheria and tetanus toxoids and pertussis vaccine is higher than ever before, measures for the control of pertussis remain problematic. In particular, the only approach for controlling pertussis among adolescents and adults is erythromycin prophylaxis or treatment. Because pertussis often is not suspected in the diagnosis of persistent cough among adolescents and adults, treatment is rarely prescribed, and the diagnosis only considered when younger family members develop pertussis.

To improve tracking progress toward the 1996 goal of eliminating Hib disease among children aged less than 5 years, additional information must be collected and reported for all cases of invasive H. influenzae disease in children aged less than 15 years. This information includes serotype of the H. influenzae isolate (type b or non-b) and vaccination status of the case; only Hib is preventable by vaccination. This and other supplementary information should be reported by state health departments on the National Bacterial Meningitis and Bacteremia Case Report form and sent to CDC's Childhood and Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Mailstop C-09, 1600 Clifton Road, NE, Atlanta, GA 30333. All state and local health departments are encouraged to ensure appropriate serotype testing is done on each H. influenzae isolate and that these results are reported to CDC.

References

1. CDC. Certification of poliomyelitis eradication -- the Americas, 1994. MMWR 1994;43:720-2.

2. CDC. Measles -- United States, first 26 weeks, 1994. MMWR 1994;43:673-6.

3. CDC. Progress toward elimination of Haemophilus influenzae type b disease among infants and children -- United States, 1987-1993. MMWR 1994;43:144-8.

4. CDC. Reported vaccine-preventable diseases -- United States, 1993, and the Childhood Immunization Initiative. MMWR 1994;43:57-60.

5. CDC. Resurgence of pertussis -- United States, 1993. MMWR 1993;42:952-3,959-60.

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