Julie Morita

Recommendations from the national vaccine advisory committee: Standards for adult immunization practice

National Vaccine Advisory Committee The Advisory Committee on Immunization Practices (ACIP) makes recommendations for routine vaccination of adults in the United States.1 Standards for implementing the ACIP recommendations for adults were published by the National Vaccine Advisory Committee (NVAC) in 20032 and by the Infectious Diseases Society of America in 2009.3 In addition, NVAC published a report in 2012 outlining a pathway for improving adult immunization rates.4 While most of these documents included guidelines for immunization practice, recent changes in the practice climate for adult immunization necessitated an update of existing adult immunization standards. Some of these changes include expansion of vaccination services offered by pharmacists and other community immunization providers both during and since the 2009 H1N1 influenza pandemic; vaccination at the workplace; increased vaccination by providers who care for pregnant women; and changes in the health-care system, including the Affordable Care Act (ACA), which requires first-dollar coverage of ACIP-recommended vaccines for people with certain private insurance plans, or those who are beneficiaries of expanded Medicaid plans.5 The ACA first-dollar provision is expected to increase the number of adults who will be insured for vaccines. Other changes include expanding the inclusion of adults in state immunization information systems (IISs) (i.e., registries) and the Centers for Medicare & Medicaid Services Meaningful Use Stage 2 requirements, which mandate provider reporting of immunizations to registries, including reporting of adult vaccination in states where such reporting is allowed.6 For the purposes of this report, provider refers to any individual who provides health-care services to adult patients, including physicians, physician assistants, nurse practitioners, nurses, pharmacists, and other health-care professionals. While previous versions of the adult immunization standards have been published, recommendations for adult vaccination are published annually, and many health-care organizations have endorsed routine assessment and vaccination of adults, vaccination among adults continues to be low.7–15 Several barriers to adult vaccination include:

Effect of a School-Entry Vaccination Requirement on Racial and Ethnic Disparities in Hepatitis B Immunization Coverage Levels Among Public School Students

OBJECTIVE. We evaluated the overall effect of Illinois’ school-entry mandate on hepatitis B vaccination coverage levels and racial/ethnic differences in vaccination coverage before and after the mandate. METHODS. In 1997, the Illinois Department of Public Health mandated hepatitis B vaccination before entry into 5th grade. We conducted a retrospective cohort study of 6 consecutive Chicago public schools’ 12th-grade classes; 4 entered 5th grade before the mandate (premandate cohorts) and 2 afterward (postmandate cohorts). We used Chicago public schools’ vaccination database and calculated annual coverage levels for 2nd through 12th grades; the cohorts entered 12th grade during 2000–2005. We compared hepatitis B vaccination coverage levels according to race/ethnicity and coverage levels for the premandate and postmandate cohorts. RESULTS. We evaluated 106 541 students. The postmandate cohort had significantly higher hepatitis B vaccination coverage levels than the premandate cohort at 5th-grade (38.2% vs 4.3%) and 9th-grade (85.0% vs 37.4%) entry. For 9th-grade students, compared with white students, black students were less likely to have received hepatitis B vaccination before the mandate; this disparity decreased for the first postmandate cohort. For Hispanic students, the disparity was less pronounced and also decreased after the mandate. By 9th grade in the postmandate cohorts, coverage levels for all racial/ethnic groups exceeded 80%. CONCLUSIONS. There was a dramatic decrease in the disparity of hepatitis B vaccination coverage between white and black or Hispanic students. School-entry requirements effectively increased hepatitis B vaccination coverage levels regardless of race or ethnicity and should be considered for other recently recommended adolescent vaccines.

African-American Children Are at Risk of a Measles Outbreak in an Inner-City Community of Chicago, 2000

BACKGROUND Since the measles resurgence of 1989-1991, which affected predominantly inner-city preschoolers, national vaccination rates have risen to record-high levels, but rates among inner-city, preschool-aged, African-American children lag behind national rates. The threat of measles importations from abroad exists and may be particularly important in large U.S. cities. To stop epidemic transmission, measles vaccination coverage should be at least 80%. OBJECTIVE To determine measles vaccination rates and predictors for having received a dose of measles-containing vaccine by age 19 to 35 months among children in an inner-city community of Chicago. METHODS We used a cross-sectional survey with probability proportional to size cluster sampling. Immunization histories from parent-held records and providers were combined to establish a complete vaccination history. RESULTS A total of 2545 households were contacted, and 170 included a resident child aged 12 to 35 months. Of these, 97% (N=165 children) agreed to participate. Immunization history from a parent or provider was not available for 20 children. Among children aged 19 to 35 months with available immunization histories, 74% received measles vaccine (n=100); of these, 84% received the vaccine as recommended at ages 12 to 15 months. However, when including children without immunization histories, measles coverage levels among children aged 19 to 35 months were 64% (n=114). Among children with records, predictors for receipt of measles vaccine by age 19 to 35 months were possessing a hand-held immunization card (odds ratio [OR]=16.8; 95% confidence interval [CI]=4.2-67.1); utilizing a public health department provider for a usual source of care (OR=8.9; 95% CI=1.6-47.2); and being up-to-date for vaccines at 3 months of age (OR=5.0; 95% CI=1.8-14.1). CONCLUSIONS Optimistically assuming that children without immunization histories are as well immunized as children with immunization histories, the measles vaccination rate among Englewoods children aged 19 to 35 months is too low to maintain immunity (74%). Measles coverage levels lagged behind coverage reported in a national survey in Chicago (86%) and the nation as a whole (92%). Efforts to raise and sustain coverage should be undertaken.

Overcoming Barriers to Low HPV Vaccine Uptake in the United States: Recommendations from the National Vaccine Advisory Committee: Approved by the National Vaccine Advisory Committee on June 9, 2015

An average of 25,900 cases of human papillomavirus (HPV)-associated cancers are newly diagnosed in the United States each year.1,2 An estimated 14 million people are newly infected with HPV each year, and nearly half of these infections occur in people aged 14–25 years.3 Although most infections resolve over time, persistent infection with oncogenic HPV types is associated with a variety of cancers. Virtually all cervical cancers are caused by HPV, along with 90% of anal, 69% of vaginal, 60% of oropharyngeal, 51% of vulvar, and 40% of penile cancers.1 Furthermore, 87% of anal, 76% of cervical, 60% of oropharyngeal, 55% of vaginal, 44% of vulva, and 29% of penile cancers are caused by oncogenic HPV type 16 or 18.4 Of the 35,000 HPV cancers reported in 2009 in the United States, 39% occurred in males.1 Three HPV vaccines are currently available in the United States. One is a bivalent vaccine (designated as HPV2) designed to protect against HPV types 16 and 18, which are responsible for the most HPV-associated cancers. One is a quadrivalent vaccine (HPV4), which protects against HPV types 16 and 18 and two additional types, 6 and 11, that are the most common causes of genital warts. One is a nonavalent vaccine (HPV9) that protects against HPV types 6, 11, 16, and 18, and offers additional protection against five oncogenic HPV types, 31, 33, 45, 52, and 58. To prevent cancers associated with HPV infections, the Advisory Committee on Immunization Practices (ACIP) recommends HPV immunization for all children aged 11 or 12 years with the licensed three-doses series. The ACIP has recommended routine HPV immunization for girls since 2006 and for boys since 2011.2 Despite ACIP’s recommendations, rates of vaccination have remained low. In 2013, initiation rates for the HPV vaccine series were just 57.3% for girls and 34.6% for boys, and completion rates were ,40% for girls and 15% for boys.2 These completion rates are well below the national Healthy People 2020 target of 80%.

Influenza-Like Illness in a Community Surrounding a School-Based Outbreak of 2009 Pandemic Influenza A (H1N1) Virus–Chicago, Illinois, 2009

In April 2009, following the first school closure due to 2009 pandemic influenza A (H1N1) (pH1N1) in Chicago, Illinois, area hospitals were inundated with patients presenting with influenza-like illness (ILI). The extent of disease spread into the surrounding community was unclear. We performed a household survey to estimate the ILI attack rate among community residents and compared reported ILI with confirmed pH1N1 cases and ILI surveillance data (ie, hospital ILI visits, influenza testing, and school absenteeism). The estimated ILI attack rate was 4.6% (95% confidence interval, 2.8%-7.4%), with cases distributed throughout the 5-week study period. In contrast, 36 (84%) of 43 confirmed pH1N1 cases were identified the week of the school closure. Trends in surveillance data peaked during the same week and rapidly decreased to near baseline. Public awareness and health care practices impact standard ILI surveillance data. Community-based surveys are a valuable tool to help assess the burden of ILI in a community.

Use of public school immunization data to determine community-level immunization coverage.

Objectives. To evaluate whether immunization data collected on a childs entry into kindergarten, i.e., Chicago Public School Immunization Data (PSID), was comparable to coverage levels determined by the National Immunization Survey (NIS) and to use these data to identify community areas with consistently low immunization coverage. Methods. The Chicago Department of Public Health obtained four years of PSID (2000–2003); these data included demographic information, home address, and immunization records. Coverage levels were determined in two ways: (1) one dose of measles-containing vaccine (MCV) and (2) four doses of diphtheria and tetanus toxoids and pertussis vaccine, three doses of poliovirus vaccine, and one dose of measles-containing vaccine (the 4:3:1 series), stratified by racial/ethnic group; these levels were compared to NIS estimates for the respective time periods. We used geographic information system software to illustrate variations in coverage levels between distinct community areas within Chicago. Results. Year 2000 MCV coverage levels determined from PSID closely approximated NIS estimates (84.6% vs. 87.2% ± 4.6%, respectively). MCV coverage levels determined by race/ethnicity from PSID were within the 95% confidence intervals (CI) for all racial categories (white, 89.5% vs. 92.2% ± 6.4%; black, 79.0% vs. 83.5% ± 9.4%; Hispanic, 89.5% vs. 87.5% ± 5.8%). Comparison of PSID and NIS 4:3:1 coverage levels revealed similar findings. For each study year, PSID identified 12 community areas with consistently low MCV coverage levels, i.e., <80%. Conclusions. PSID closely approximated NIS coverage estimates for MCV and 4:3:1 immunization. These methods can be used by state and city health departments to identify and direct resources to communities at greatest need.

Measles Immunization Coverage Determined by Serology and Immunization Record from Children in Two Chicago Communities

Objectives. We compared the prevalence of measles immunization determined by serology with the prevalence of measles immunization determined by immunization records, and identified factors predictive of measles immunization among a sample of children from two Chicago communities. Methods. We collected demographic information and blood specimens from a sample of children aged 12–71 months in two Chicago communities at risk for low measles immunization coverage levels. We collected immunization information from provider records, parent-held records, and the statewide immunization registry. We compared evidence of immunization determined by serology with evidence of immunization from these three sources of immunization records. Results. The sample of children from the two communities had serologic measles immunity levels of 85% and 90%. Significantly fewer children had evidence of immunization by record in both communities (45% and 63%, respectively). Conclusions. Immunization coverage levels determined using immunization records were significantly lower than immunization coverage determined using serology. A fully populated immunization registry used by all immunization providers could prevent the problems of record loss and scatter.

Successful Use of Interventions in Combination to Improve Human Papillomavirus Vaccination Coverage Rates Among Adolescents—Chicago, 2013 to 2015

In 2013, National Immunization Survey-Teen data indicated that >40% of female adolescents had not initiated the human papillomavirus (HPV) vaccine series and >60% had not completed the series, documenting vaccination rates much lower than those for other vaccines recommended for adolescents. The Chicago Department of Public Health (CDPH) was 1 of 22 jurisdictions nationwide to receive a Prevention and Public Health Fund award through the Centers for Disease Control and Prevention to improve HPV vaccination rates among adolescents. The CDPH implemented 5 interventions targeting the public, clinicians and their staff, and diverse immunization and cancer prevention stakeholders. Compared with 2013 jurisdiction-specific HPV vaccination rates among all adolescents, Chicagos HPV vaccination rates were increased significantly in 2014 and 2015. This article details the methods and results of Chicagos successful interventions, the particular strengths as well as barriers encountered, and future steps necessary for sustaining improvement.

A 9-Valent HPV Vaccine in Women

To the Editor: Joura et al. (Feb. 19 issue)1 report that the 9-valent vaccine against human papillomavirus (9vHPV) had an efficacy of 96.7% to prevent high-grade cervical, vulvar, or vaginal dysplasia related to HPV types 31, 33, 45, 52, and 58 in women. Men who are positive for the human immunodeficiency virus and who have sex with men (HIV+MSM) have a strongly increased risk of persistent anogenital HPV infection and associated anal or penile intraepithelial neoplasia (AIN or PIN) and cancer.2,3 The quadrivalent HPV vaccine effectively prevents disease related to HPV types 6, 11, 16, and 18 in both women and men.4,5 We have analyzed the HPV spectrum in 451 biopsy specimens of AIN, PIN, and anal and penile cancer obtained from men categorized as HIV+MSM (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org).2 Although only 45% of the lesions carried HPV types covered by the quadrivalent HPV vaccine, 68% of the HPV types are likely to be covered by the 9vHPV vaccine. Most important, 55% of anal and penile cancers carried the five HPV types that are included only in the 9vHPV vaccine. Unfortunately, HPV vaccination of boys and male adolescents is not yet recommended in several countries that cover HPV vaccination of girls in their national vaccination programs. If future studies show that the 9vHPV vaccine is as effective in men as in women, this vaccine should not be withheld from males.

Leveraging community concerns regarding meningococcal disease to address racial and socioeconomic disparities in immunization coverage.

Following the death of 2 adolescents due to serogroup C invasive meningococcal disease (SCIMD) in April 2008, the Chicago Department of Public Health (CDPH) observed a high level of concern in 2 Chicago communities inferred to have low meningococcal vaccine (MCV) coverage rates. In response, CDPH promptly mobilized additional resources, administering 5,343 doses of MCV in 40 schools over 2 weeks and immunizing 44% of enrolled students aged 11 to 18 years. The number of eligible students vaccinated per school ranged from 9 to 466 (median, 112) and the proportion of age-eligible students receiving the vaccine ranged from 5% to 87% (median, 52%). The attributes of the SCIMD activity did not meet the definition of a community-based outbreak, but presented an opportunity to promptly intensify existing mechanisms for meningococcal vaccination of adolescents in the affected neighborhoods and overcome traditional barriers to vaccination.