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Research, funding, delivery still major hurdles for immunization programs
Walter Orenstein, MD, received the Charles Mérieux award for his efforts against vaccine-preventable illnesses at the Annual Conference on Vaccine Research.
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BALTIMORE — Research and funding for new vaccines, as well as strong immunization programs, are crucial for prevention or reduction of the burden associated with infectious diseases, according to Walter A. Orenstein, MD.
Orenstein, associate director of the Emory Vaccine Center and Infectious Diseases in Children editorial board member, presented information about the challenges and future of vaccines at the Charles Mérieux Award luncheon at the National Foundation for Infectious Diseases’ 10th Annual Conference on Vaccine Research.
The NFID presented Orenstein with the Charles Mérieux Award in recognition of his work toward infectious disease reduction through vaccines.
“Dr. Orenstein’s extensive contributions to the field of vaccinology make him an excellent choice to receive NFID’s Mérieux Award,” said Susan J. Rehm, MD, medical director for the NFID. “He is responsible for helping to expand vaccine usage, and in doing so, he has contributed to the control or even elimination of deadly diseases in the United States and around the world.”
Orenstein discussed challenges to the continuing success of the immunization program, including financing of new vaccines and new vaccine recommendations, which he viewed as potentially the most critical problem. The cost of vaccines included in the routine immunization schedule for children and adolescents increased 10-fold in the past 20 years, according to Orenstein. Pediatricians are angry about adequate and timely reimbursement and the substantial nonvaccine-related costs, he said.
“In my almost 30 years working in immunization, I have never seen pediatricians angrier,” Orenstein said.
Vaccination strategies
Orenstein said that the real goal of a successful immunization program is not the number of new vaccines created, but the number of cases of disease prevented.
“[T]he word ‘vaccine’ does not mean ‘vaccination.’ A vaccine is essential for vaccination but not sufficient. For successful vaccination, we must have effective immunization programs. And effective immunization programs rely on the input of a variety of scientific disciplines, particularly those involved in the behavioral sciences, epidemiology, economics, communications and others,” Orenstein said.
Although the perfect vaccine, which would be 100% effective and safe, have no contraindications or require more than a single dose for lifetime protection and not have any transport restrictions, is not something Orenstein “holds his breath on,” using available vaccines more effectively is essential, he gave the worldwide effort against measles as an example.
Although a better vaccine would be ideal, Ciro de Quadros and the Pan American Health Organization (PAHO) were able to stage a successful measles elimination campaign in the western hemisphere. The components of the organizations’ strategy included 1) routine immunization at age 9 months and 2) mass campaigns with social mobilization and community outreach targeting children aged 9 months to 14 years regardless of prior immunization status. This gives a second dose to those previously vaccinated through routine immunization to reduce vaccine failure and perhaps, more importantly provides a first dose for children who do not have access to health services. Other components include: 3) disease surveillance and 4) follow-up campaigns every three to five years providing a dose of measles vaccine to all children born since the last campaign regardless of prior vaccination status, thereby providing a second opportunity at vaccination, according to Orenstein.
“Thus, although we all would like a measles vaccine that is more effective at younger ages than the present one that could be delivered by a route that is easier to administer than needle and syringe, we can still make considerable headway through innovative vaccination programs,” Orenstein said.
Measles is no longer endemic in the Americas. The strategy used in the Americas is now being used worldwide and has led to a 60% reduction in measles mortality. Globally, WHO estimated 873,000 measles deaths in 1999 versus 345,000 deaths in 2005.
Orenstein also pointed out a major concern with some vaccines is vaccine failure. For example, in the United States during the 1980s, measles outbreaks occurred in school-age children, the great majority of whom had received a single dose of measles vaccine. This led to the recommendation for a second dose. However, a much greater problem than vaccine failure was failure to vaccinate. A single dose of measles vaccine at 12 to 15 months of age is 95% to 98% effective. In contrast, failure to provide the first dose of vaccine is 0% effective. Recognizing the importance of vaccinating children as preschoolers at the recommended time changed the focus of the immunization program; trying to understand the reasons for lack of vaccination became a top priority. Previous assumptions regarding lack of immunization among infants placed the blame on parents, according to Orenstein. However, studies during the late 1980s and early 1990s found that the medical community missed many vaccination opportunities when children made health care visits and were eligible for vaccines and did not receive them. In addition, a study of inner city children evaluating parental attitudes found they did not correlate with immunization coverage of their children. Parents who worried about disease were no more likely to immunize their children than parents who did not worry about disease, he said. The study also found, paradoxically, that immunization coverage among children at 7 months of age whose mothers believed vaccination provided a great deal of benefit was lower than those who did not think the vaccine was helpful. This suggested that parents gave the responsibility of vaccination to their children’s health care providers. In addition health services research documented physicians tended to overestimate immunization coverage of their patients. Those that felt their patients were highly immunized would not be motivated to change their practices to improve coverage. Based on the above information, efforts to achieve higher immunization rates were focused on improving provider performance as the major strategy. Immunization coverage since the late 1990s has been greater than 90% for most individual vaccines.
Future for disease prevention
The number of diseases against which all children are recommended to be vaccinated has doubled from eight to 16 during the past 20 years, according to Orenstein. Since 2004, the vaccine schedule has grown to include an adolescent pertussis booster, human papillomavirus vaccine, meningococcal conjugate vaccine, rotavirus vaccine, hepatitis A vaccine, influenza vaccine for all children aged 6 to 59 months, and a second dose of varicella vaccine.
There is substantial concern regarding adequate government and private financing for both the costs of the vaccines and the substantial non-vaccine costs associated with providing immunizations. A major priority must be to seek and obtain sufficient reimbursement of these costs for physicians along with a reasonable return on investment. The nonvaccine costs are not sufficiently appreciated by both third party payers and the government.
Vaccine delivery to adolescents and improved coverage among adults are also important issues, Orenstein said. Adolescents do not make frequent well-child visits, but it is now recommended that, in addition to tetanus and diphtheria toxoids vaccine, adolescents should receive pertussis booster and meningococcal vaccine, and girls should receive the HPV vaccine. Orenstein recommends research to determine whether successful vaccination of adolescents can occur at their physician’s office or whether other delivery methods will be able to better immunize adolescents while not harming the delivery of other services in the medical home. He also recommends further research on identifying parents who are opposed to vaccines to better address the issue of parental refusal.
“I could not let slip an opportunity to discuss how we might decrease morbidity and mortality with the greatest vaccine-preventable cause of morbidity and mortality: influenza,” Orenstein said.
Most immunization programs focus on those most at risk, such as the elderly, but Orenstein recommended further research to determine whether mass vaccination campaigns aimed at younger populations and “key transmitters,” including school-aged children, would reduce the overall burden of influenza throughout the community.
“I am honored to receive the Mérieux Award, which I view as recognition not so much of my own work, but of the work of so many unsung heroes who have placed vaccination, the use of vaccines, at the top of the list of effective prevention programs,” Orenstein said. – by Lauren Riley
For more information:
- Orenstein WA. Moving vaccines to vaccination: achieving optimal control of disease. Presented at: The National Foundation for Infectious Diseases’ 10th Annual Conference on Vaccine Research; April 29-May 2, 2007; Baltimore.