Frederic E. Shaw

The Patient Protection and Affordable Care Act: opportunities for prevention and public health

The Patient Protection and Affordable Care Act, which was enacted by the US Congress in 2010, marks the greatest change in US health policy since the 1960s. The law is intended to address fundamental problems within the US health system, including the high and rising cost of care, inadequate access to health insurance and health services for many Americans, and low health-care efficiency and quality. By 2019, the law will bring health coverage--and the health benefits of insurance--to an estimated 25 million more Americans. It has already restrained discriminatory insurance practices, made coverage more affordable, and realised new provisions to curb costs (including tests of new health-care delivery models). The new law establishes the first National Prevention Strategy, adds substantial new funding for prevention and public health programmes, and promotes the use of recommended clinical preventive services and other measures, and thus represents a major opportunity for prevention and public health. The law also provides impetus for greater collaboration between the US health-care and public health systems, which have traditionally operated separately with little interaction. Taken together, the various effects of the Patient Protection and Affordable Care Act can advance the health of the US population.

Intradermal hepatitis B vaccination in a large hospital employee population

The intradermal route of hepatitis B vaccine administration has been tested in several clinical trials and has produced various degrees of immunogenicity, but usually among small groups of participants. To assess more adequately the immunogenicity of hepatitis B vaccine using the intradermal route, the Centers for Disease Control conducted a clinical trial among 425 well health-care workers in a hospital setting. Participants were randomly assigned to one of two treatment groups: those receiving a 20 micrograms intramuscular injection, and those receiving a 2 micrograms intradermal injection. Participants received the plasma-derived hepatitis B vaccine by the standard schedule at 0, 1 and 6 months, and serum samples were collected at 3, 8, 12 and 24 months after the first dose. Antibody response rates (anti-HBs titre greater than or equal to 10 sample ratio units by radioimmunoassay) for the intradermal vaccination group were consistently lower than those for the intramuscular vaccination group at each testing interval. The differences were greatest for the 3-month test and decreased over time. Geometric mean titres for anti-HBs for the intradermal group were significantly lower than those for the intramuscular group at the 8-month test point. In addition to inoculation route, factors of gender, smoking and age were found to have significant effects on immune response. The results suggest that intradermal vaccination with hepatitis B vaccine may be appropriate under certain conditions and for certain population subgroups.

Use of Hepatitis A Vaccine in a Community-Wide Outbreak of Hepatitis A

Hepatitis A outbreaks in communities are often difficult to control. From July 1994 through June 1995, 676 cases of hepatitis A were reported in Shelby County, Tennessee. With the licensure of a hepatitis A vaccine in February 1995, a new tool for outbreak control became available. During August-October 1995, a mass vaccination campaign was conducted. A total of 34,054 children received the first dose of hepatitis A vaccine. From December 1995 through December 1996, the number of hepatitis A cases reported inside the intervention area declined by 64%; outside the intervention area, the number of cases declined by 40%. The precise contribution of the vaccine campaign to the decline in the number of outbreak cases is difficult to quantify because community outbreaks often wane over time. The vaccine campaign may have hastened the decline of the number of outbreak cases. Future interventions should consider an earlier campaign with greater vaccine coverage.

Legal basis of consent for health care and vaccination for adolescents.

State law is generally the controlling authority for whether parental consent is required or minors may consent for their own health care, including vaccination. At the federal level, no vaccination consent law exists; however, federal law requires that vaccine information statements be given to the parent or another person who is qualified under state law to consent to vaccination of a minor. All states allow minors to consent for their own health care in some circumstances on the basis of either (1) their status (eg, age, emancipation, marriage) or (2) the kind of health care services they are seeking (eg, family planning services, treatment of sexually transmitted disease). In each state, a specific analysis of laws will be required to determine the circumstances under which a minor can consent for vaccination.

Clinical Preventive Services Coverage and the Affordable Care Act

The Affordable Care Act requires many health plans to provide coverage for certain recommended clinical preventive services without charging copays or deductible payments. This provision could lead to greater uptake of many services that can improve health and save lives. Although the coverage provision is broad, there are many caveats that also apply. It is important for providers and public health professionals to understand the nuances of the coverage rules to help maximize their potential to improve population health.

Delivering New Vaccines to Adolescents: The Role of School-Entry Laws

In the United States, state-based school-entry vaccination laws have been used effectively to rapidly increase vaccination rates among adolescents, in particular, for hepatitis B vaccine. New vaccines for adolescents raise the question of whether and under what circumstances school-entry laws may be used to increase coverage rates with these vaccines. The new vaccines differ somewhat from their predecessors and raise policy and legal issues. For example, some of the new vaccines prevent diseases for which the primary mode of transmission is sexual contact. Mandating these vaccines before school entry has been met with concern by those who believe that mandates for this type of vaccine not only intrude on parental decision-making rights but might also lead to sexual promiscuity among youth. In this article we explore (1) the possible utility of school-entry requirements to increase the delivery of the new vaccines for adolescents, including the legal basis for US school-entry laws, (2) arguments in favor and concerns about the adoption of laws for adolescent vaccination, and (3) the importance of including diverse stakeholders in the deliberative process and formulating and implementing laws in a way that maximizes their acceptance and effectiveness.

New Adolescent Vaccines: Legal and Legislative Issues

journal of law, medicine & ethics Lance Rodewald The Routine Childhood Immunization Schedule1 prevents about 33,000 premature deaths each year, prevents about 14.5 million cases of vaccine-preventable deaths each year for each birth cohort vaccinated, and saves society about

Celebrating 140 Years of Public Health Reports

42 billion, including about

Postmarketing surveillance for neurologic adverse events reported after hepatitis B vaccination: experience of the first three years

10.5 billion in direct medical costs, and so provides a huge benefit to society. This discussion will concentrate on part of the adolescent component of the Centers for Disease Control and Prevention (CDC) vaccination schedule.2 In spite of high coverage rates for preschool-age children, adolescents in the United States have not enjoyed as high a level of protection from vaccine preventable diseases. Adolescents are a group public health authorities struggle to reach. There are three reasons to do better. First, the vaccination schedule tries to protect adolescents before their exposure to disease. Rates of bacterial meningitis infection show that occurrences of invasive meningococcal disease peak in the adolescent years, and again when individuals are living in close quarters in college dormitories. Bacterial meningitis can occur in massive outbreaks in which young or college-age children die from invasive meningococcal disease, and then expose other individuals, leading to panic in the community. The meningococcal conjugate vaccine licensed last year for adolescents is a single dose and is very effective. Second, pertussis generally occurs in young babies, the age associated with the greatest risk of serious morbidity or even death. But pertussis epidemiology contains a paradox: even though vaccine coverage rates among very young children are high, the overall rate occurrence of pertussis is increasing. In 2004, pertussis vaccination levels among children 19-35 months of age were the highest ever recorded, but that same year the highest number of pertussis cases was recorded since 1959. From 1990 until 2004, the rate of disease among adolescents 11-18 years old saw the largest increase. Prior to 2005, pertussis vaccine could not be given after age seven years because of the high rate of adverse events from the whole cell pertussis vaccine among older children. Because vaccine-induced immunity wanes after about 10 years, adolescents and adults became the new, susceptible reservoir of disease. They have been contracting pertussis and spreading the virus to young babies too young to be vaccinated. The availability of the new, acellular pertussis vaccine for adolescents has allowed public health officials to launch a new campaign, with two phases: vaccination of adolescents, and vaccination of adults. The third reason to have a good adolescent platform is the human papillomavirus (HPV) vaccine. HPV is a very prevalent, sexually transmitted infection. The first HPV infection usually occurs around the time of sexual debut because this virus is ubiquitous. Infection with multiple types of HPV is not uncommon. The infection can be transient and is usually associated with no symptoms. Persistent infection with high-risk types of HPV is the most important risk-factor for cervical cancer precursors and cervical cancer. HPV infection has a huge clinical impact in the United States. Annual estimates have found about 2.8 million abnormal pap smears primarily related to HPV, 10,000 cases of cervical cancer, and about 3,900 deaths from cervical cancer each year. HPV also causes genital warts, which has a large burden of disease. Current estimates are that 20 million people are infected, 15% of people ages 15-49 years are currently infected, 6.2 million infections happen each year, and over 50% of sexually active men and women acquire New Adolescent Vaccines: Legal and Legislative Issues

Lethal Outbreak of Hepatitis B in a Dental Practice

On July 13, 2018, Public Health Reports marks its 140th year of publication. It began in 1878 as a small weekly government bulletin of disease reports and tables. During the past 140 years, this, the official journal of the surgeon general and the US Public Health Service (USPHS), has adapted continually to new public health challenges and innovations in medical communications (Box). From a simple bulletin publishing mostly reports from USPHS officers, through the decades the journal has evolved into a seasoned peerreviewed journal publishing articles from all parts of the public health enterprise. In this editorial, we celebrate the journal’s anniversary and the contributions it has made to public health. We offer a short history of the journal; announce the reinstatement of Public Health Chronicles, a department in the journal dedicated to the history of public health; and reflect on the future of the journal.