 |
Achievements in Public Health, 1900-1999 Impact of Vaccines Universally
Recommended for Children -- United States, 1990-1998
At the beginning of the 20th
century, infectious diseases were widely prevalent in the United States and
exacted an enormous toll on the population. For example, in 1900, 21,064
smallpox cases were reported, and 894 patients died (1). In 1920,
469,924 measles cases were reported, and 7575 patients died; 147,991
diphtheria cases were reported, and 13,170 patients died. In 1922, 107,473
pertussis cases were reported, and 5099 patients died (2,3).
In 1900, few effective treatment and preventive measures existed to
prevent infectious diseases. Although the first vaccine against smallpox was
developed in 1796, greater than 100 years later its use had not been
widespread enough to fully control the disease (4). Four other vaccines --
against rabies, typhoid, cholera, and plague -- had been developed late in
the 19th century but were not used widely by 1900.
Since 1900, vaccines have been developed or licensed against 21 other
diseases (5) (Table_1). Ten of these vaccines
have been recommended for use only in selected populations at high risk
because of area of residence, age, medical condition, or risk behaviors. The
other 11 have been recommended for use in all U.S. children (6).
During the 20th century, substantial achievements have been made in the
control of many vaccine-preventable diseases. This report documents the
decline in morbidity from nine vaccine-preventable diseases and their
complications -- smallpox, along with the eight diseases for which vaccines
had been recommended for universal use in children as of 1990 (Table_2).
Four of these diseases are detailed: smallpox has been eradicated,
poliomyelitis caused by wild-type viruses has been eliminated, and measles
and Haemophilus influenzae type b (Hib) invasive disease among children aged
less than 5 years have been reduced to record low numbers of cases.
Information about disease and death during the 20th century was obtained
from the MMWR annual summaries of notifiable diseases and reports by the
U.S. Department of Health, Education, and Welfare. For smallpox, Hib, and
congenital rubella syndrome (CRS), published studies were used (2,3,7-14).
Current Delivery and Use of Vaccines
National efforts to promote vaccine use among all children began with the
appropriation of federal funds for polio vaccination after introduction of
the vaccine in 1955 (5). Since then, federal, state, and local governments
and public and private health-care providers have collaborated to develop
and maintain the vaccine-delivery system in the United States.
Overall, U.S. vaccination coverage is at record high levels. In 1997,
coverage among children aged 19-35 months (median age: 27 months) exceeded
90% for three or more doses of diphtheria and tetanus toxoids and pertussis
vaccine (DTP), three or more doses of poliovirus vaccine, three or more
doses of Hib vaccine, and one or more doses of measles-containing vaccine.
Coverage with four doses of DTP was 81% and for three doses of hepatitis B
vaccine was 84%. Coverage was substantially lower for the recently
introduced varicella vaccine (26%) and for the combined series of four
DTP/three polio/one measles-containing vaccine/three Hib (76%) (15).
Coverage for rotavirus vaccine, licensed in December 1998, has not yet been
measured among children aged 19-35 months. Coverage among children aged 5-6
years has exceeded 95% each school year since 1980 for DTP; polio; and
measles, mumps, and rubella vaccines (CDC, unpublished data, 1998).
Vaccine Impact
Dramatic declines in morbidity have been reported for the nine
vaccine-preventable diseases for which vaccination was universally
recommended for use in children before 1990 (excluding hepatitis B,
rotavirus, and varicella) (Table_2). Morbidity
associated with smallpox and polio caused by wild-type viruses has declined
100% and nearly 100% for each of the other seven diseases.
Smallpox. Smallpox is the only disease that has been eradicated. During
1900-1904, an average of 48,164 cases and 1528 deaths caused by both the
severe (variola major) and milder (variola minor) forms of smallpox were
reported each year in the United States (1). The pattern in the decline of
smallpox was sporadic. Outbreaks of variola major occurred periodically in
the first quarter of the 1900s and then ceased abruptly in 1929. Outbreaks
of variola minor declined in the 1940s, and the last case in the United
States was reported in 1949. The eradication of smallpox in 1977 enabled the
discontinuation of prevention and treatment efforts, including routine
vaccination. As a result, in 1985 the United States recouped its investment
in worldwide eradication every 26 days (1).
Polio. Polio vaccine was licensed in the United States in 1955. During
1951-1954, an average of 16,316 paralytic polio cases and 1879 deaths from
polio were reported each year (9,10). Polio incidence declined sharply
following the introduction of vaccine to less than 1000 cases in 1962 and
remained below 100 cases after that year. In 1994, every dollar spent to
administer oral poliovirus vaccine saved $3.40 in direct medical costs and
$2.74 in indirect societal costs (14). The last documented indigenous
transmission of wild poliovirus in the United States occurred in 1979. Since
then, reported cases have been either vaccine-associated or imported. As of
1991, polio caused by wild-type viruses has been eliminated from the Western
Hemisphere (16). Enhanced use of the inactivated polio vaccine is expected
to reduce the number of vaccine-associated cases, which averaged eight cases
per year during 1980-1994 (17).
Measles. Measles vaccine was licensed in the United States in 1963.
During 1958-1962, an average of 503,282 measles cases and 432
measles-associated deaths were reported each year (9-11). Measles incidence
and deaths began to decline in 1965 and continued a 33-year downward trend.
This trend was interrupted by epidemics in 1970-1972, 1976-1978, and
1989-1991. In 1998, measles reached a provisional record low number of 89
cases with no measles-associated deaths (13). All cases in 1998 were either
documented to be associated with international importations (69 cases) or
believed to be associated with international importations (CDC, unpublished
data, 1998). In 1994, every dollar spent to purchase measles-containing
vaccine saved $10.30 in direct medical costs and $3.20 in indirect societal
costs (7).
Hib. The first Hib vaccines were polysaccharide products licensed in 1985
for use in children aged 18-24 months. Polysaccharide-protein conjugate
vaccines were licensed subsequently for use in children aged 18 months (in
1987) and later for use in children aged 2 months (in 1990). Before the
first vaccine was licensed, an estimated 20,000 cases of Hib invasive
disease occurred each year, and Hib was the leading cause of childhood
bacterial meningitis and postnatal mental retardation (8,18). The incidence
of disease declined slowly after licensure of the polysaccharide vaccine;
the decline accelerated after the 1987 introduction of
polysaccharide-protein conjugate vaccines for toddlers and the 1990
recommendation to vaccinate infants. In 1998, 125 cases of Hib disease and
Haemophilis influenzae invasive disease of unknown serotype among children
aged less than 5 years were provisionally reported: 54 were Hib and 71 were
of unknown serotype (CDC, unpublished data, 1998). In less than a decade,
the use of the Hib conjugate vaccines nearly eliminated Hib invasive disease
among children.
Future Direction
Vaccines are one of the greatest achievements of biomedical science and
public health. Despite remarkable progress, several challenges face the U.S.
vaccine-delivery system. The infrastructure of the system must be capable of
successfully implementing an increasingly complex vaccination schedule. An
estimated 11,000 children are born each day in the United States, each
requiring 15-19 doses of vaccine by age 18 months to be protected against 11
childhood diseases (6). In addition, licensure of new vaccines is
anticipated against pneumococcal and meningococcal infections, influenza,
parainfluenza, respiratory syncytial virus (RSV), and against chronic
diseases (e.g., gastric ulcers, cancer caused by Helicobacter pylori,
cervical cancer caused by human papilloma virus, and rheumatic heart disease
that occurs as a sequela of group A streptococcal infection). Clinical
trials are under way for vaccines to prevent human immunodeficiency virus
infection, the cause of acquired immunodeficiency syndrome.
To achieve the full potential of vaccines, parents must recognize
vaccines as a means of mobilizing the body's natural defenses and be better
prepared to seek vaccinations for their children; health-care providers must
be aware of the latest developments and recommendations; vaccine supplies
and financing must be made more secure, especially for new vaccines;
researchers must address increasingly complex questions about safety,
efficacy, and vaccine delivery and pursue new approaches to vaccine
administration more aggressively; and information technology to support
timely vaccinations must be harnessed more effectively. In addition, the
vaccine-delivery system must be extended to new populations of adolescents
and adults. Each year, thousands of cases of potentially preventable
influenza, pneumococcal disease, and hepatitis B occur in these populations.
Many of the new vaccines will be targeted at these age groups. The U.S.
vaccine-delivery system must routinely include these populations to
optimally prevent disease, disability, and death.
Despite the dramatic declines in vaccine-preventable diseases, such
diseases persist, particularly in developing countries. The United States
has joined many international partners, including the World Health
Organization and Rotary International, in seeking to eradicate polio by the
end of 2000. Efforts to accelerate control of measles, which causes
approximately one million deaths each year (5), and to expand rubella
vaccination programs also are under way around the world. Efforts are needed
to expand the use of existing vaccines in routine childhood vaccination
programs worldwide and to successfully introduce new vaccines as they are
developed. Such efforts can benefit the United States and other developed
countries by decreasing disease importations from developing countries.
Reported by: National Immunization Program, CDC.
References
- Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its
eradication. Geneva, Switzerland: World Health Organization, 1988.
- US Department of Health, Education, and Welfare. Vital statistics --
special report, national summaries: reported incidence of selected
notifiable diseases, United States, each division and state, 1920-50.
Washington, DC: US Department of Health, Education, and Welfare, Public
Health Service, National Office of Vital Statistics, 1953:37.
- US Department of Health, Education, and Welfare. Vital statistics
rates in the United States, 1940-1960. Washington, DC: US Department of
Health, Education, and Welfare, Public Health Service, National Center for
Health Statistics, 1968.
- Duffy J. The sanitarians: a history of public health. Urbana,
Illinois: University of Illinois Press, 1990.
- Plotkin SA, Orenstein WA. Vaccines. 3rd ed. Philadelphia,
Pennsylvania: WB Saunders Co., 1999.
- CDC. Recommended childhood immunization schedule -- United States,
1999. MMWR 1999;48:12-6.
- Batelle Medical Technology Assessment and Policy Reserach Program,
Centers for Public Health Research and Evaluation. A cost benefit analysis
of the measles-mumps-rubella (MMR) vaccine. Arlington, Virginia: Batelle,
1994.
- Cochi SL, Ward JI. Haemophilus influenzae type b. In: Evans AS,
Brachman PS, eds. Bacterial infections of humans. New York, New York:
Plenum Medical Book Co., 1991
- CDC. Annual summary 1980: reported morbidity and mortality in the
United States. MMWR 1981;29.
- CDC. Reported incidence of notifiable diseases in the United States,
1960. MMWR 1961;9.
- CDC. Reported morbidity and mortality in the United States, 1970. MMWR
1971;19.
- CDC. Provisional cases of selected notifiable diseases, United States,
cumulative, week ending January 2, 1999 (52nd week). MMWR 1999;47:1125.
- CDC. Provisional cases of selected notifiable diseases preventable by
vaccination, United States, weeks ending January 2, 1999, and December 27,
1997 (52nd week). MMWR 1999;47:1128-9.
- Batelle Medical Technology Assessment and Policy Research Program,
Centers for Public Health Research and Evaluation. A cost benefit analysis
of the OPV vaccine. Arlington, Virginia: Batelle, 1994.
- CDC. National, state, and urban area vaccination coverage levels among
children aged 19-35 months -- United States, 1997. MMWR 1998;47:547-54.
- CDC. Certification of poliomyelitis eradication -- the Americas, 1994.
MMWR 1994;43:720-2.
- CDC. Paralytic poliomyelitis -- United States, 1980-1994. MMWR
1997;46:79-83.
- Yeargin-Allsopp M, Murphy CC, Cordero JF, Decoufle P, Hollowell JG.
Reported biomedical causes and associated medical conditions for mental
retardation among 10-year-old children, metropolitan Atlanta, 1985-1987.
Developmental Medicine and Neurology 1997;39:142-9.
Table_1
To print large tables and graphs users may have to change their printer
settings to landscape and use a small font size.
TABLE 1. Vaccine-preventable diseases, by year of vaccine development or licensure
-- United States, 1798-1998
===================================================================================
Disease Year
----------------------------------------------
Smallpox* 1798+
Rabies 1885+
Typhoid 1896+
Cholera 1896+
Plague 1897+
Diphtheria* 1923+
Pertussis* 1926+
Tetanus* 1927+
Tuberculosis 1927+
Influenza 1945&
Yellow fever 1953&
Poliomyelitis* 1955&
Measles* 1963&
Mumps* 1967&
Rubella* 1969&
Anthrax 1970&
Meningitis 1975&
Pneumonia 1977&
Adenovirus 1980&
Hepatitis B* 1981&
Haemophilus
influenzae type b* 1985&
Japanese
encephalitis 1992&
Hepatitis A 1995&
Varicella* 1995&
Lyme disease 1998&
Rotavirus* 1998&
----------------------------------------------
* Vaccine recommended for universal use in U.S. children. For smallpox, routine vaccination
was ended in 1971.
+ Vaccine developed (i.e., first published results of vaccine usage).
& Vaccine licensed for use in United States.
=========================================================================================
Return to top.
Table_2
To print large tables and graphs users may have to change their printer
settings to landscape and use a small font size.
TABLE 2. Baseline 20th century annual morbidity and 1998 provisional morbidity from
nine diseases with vaccines recommended before 1990 for universal use in children
-- United States
===============================================================================================
Baseline 20th century 1998 Provisional %
Disease annual morbidity morbidity Decrease
--------------------------------------------------------------------------------------
Smallpox 48,164* 0 100%
Diphtheria 175,885+ 1 100%&
Pertussis 147,271@ 6,279 95.7%
Tetanus 1,314** 34 97.4%
Poliomyelitis (paralytic) 16,316++ 0&& 100%
Measles 503,282@@ 89 100%&
Mumps 152,209*** 606 99.6%
Rubella 47,745+++ 345 99.3%
Congenital rubella 823&&& 5 99.4%
syndrome
Haemophilus 20,000@@@ 54**** 99.7%
influenzae type b
--------------------------------------------------------------------------------------
* Average annual number of cases during 1900-1904 ( 1 ).
+ Average annual number of reported cases during 1920-1922, 3 years before vaccine
development.
& Rounded to nearest tenth.
@ Average annual number of reported cases during 1922-1925, 4 years before vaccine
development.
** Estimated number of cases based on reported number of deaths during 1922-1926
assuming a case-fatality rate of 90%.
++ Average annual number of reported cases during 1951-1954, 4 years before vaccine
licensure.
&& Excludes one cases of vaccine-associated polio reported in 1998.
@@ Average annual number of reported cases during 1958-1962, 5 years before vaccine
licensure.
*** Number of reported cases in 1968, the first year reporting began and the first year after
vaccine licensure.
+++ Average annual number of reported cases during 1966-1968, 3 years before vaccine
licensure.
&&& Estimated number of cases based on seroprevalence data in the population and on the
risk that women infected during a childbearing year would have a fetus with congenital
rubella syndrome ( 7 ).
@@@ Estimated number of cases from population-based surveillance studies before vaccine
licensure in 1985 ( 8 ).
**** Excludes 71 cases of Haemophilus influenzae disease of unknown serotype.
================================================================================================
Return to top.
All MMWR HTML versions of articles are electronic
conversions from ASCII text into HTML. This conversion may have resulted in
character translation or format errors in the HTML version. Users should not
rely on this HTML document, but are referred to the electronic PDF version
and/or the original MMWR paper copy for the official text, figures,
and tables. An original paper copy of this issue can be obtained from the
Superintendent of Documents, U.S. Government Printing Office (GPO),
Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for
current prices.
**Questions or messages regarding errors in formatting should be
addressed to mmwrq@cdc.gov.
Page converted: 04/01/99 |
|
