Elimination of cervical cancer: Lessons learned from polio and earlier eradication programs.

This paper reviews definitions of control, elimination, and eradication and considers lessons learned from prior and current elimination/eradication efforts that might inform the current effort to eliminate cervical cancer. This task is complicated by the varying definitions of elimination extant. Lessons for cervical cancer elimination notably include the necessity for political will/champions; the need for a specific target with a time span; the need for program efforts to be guided by surveillance of disease and death (not just coverage); the need for accountability, monitoring, and evaluation at all levels; and the need for ongoing research. Although achieving the goal of elimination will be difficult, success will mean the prevention of millions of deaths due to cervical cancer.

What Is Needed to Eliminate Hepatitis B Virus and Hepatitis C Virus as Global Health Threats.

Hepatitis B virus (HBV) and hepatitis C virus (HCV) cause 1.3 million deaths annually. To prevent more than 7 million deaths by 2030, the World Health Organization set goals to eliminate HBV and HCV, defined as a 90% reduction in new infections and a 65% reduction in deaths, and prevent more than 7 million related deaths by 2030. Elimination of HBV and HCV is feasible because of characteristics of the viruses, reliable diagnostic tools, and available cost-effective or cost-saving interventions. Broad implementation of infant immunization against HBV, blood safety, and infection-control programs have greatly reduced the burden of HBV and HCV infections. To achieve elimination, priorities include implementation of HBV vaccine-based strategies to prevent perinatal transmission, safe injection practices and HCV treatment for persons who inject drugs, and testing and treatment for HBV- and HCV-infected persons. With sufficient capacity, HBV and HCV elimination programs can meet their goals.

Transition Planning For After Polio Eradication.

The Global Polio Eradication Initiative (GPEI) has been in operation since 1988, now spends $1 billion annually, and operates through thousands of staff and millions of volunteers in dozens of countries. It has brought polio to the brink of eradication. After eradication is achieved, what should happen to the substantial assets, capabilities, and lessons of the GPEI? To answer this question, an extensive process of transition planning is underway. There is an absolute need to maintain and mainstream some of the functions, to keep the world polio-free. There is also considerable risk-and, if seized, substantial opportunity-for other health programs and priorities. And critical lessons have been learned that can be used to address other health priorities. Planning has started in the 16 countries where GPEI's footprint is the greatest and in the program's 5 core agencies. Even though poliovirus transmission has not yet been stopped globally, this planning process is gaining momentum, and some plans are taking early shape. This is a complex area of work-with difficult technical, financial, and political elements. There is no significant precedent. There is forward motion and a willingness on many sides to understand and address the risks and to explore the opportunities. Very substantial investments have been made, over 30 years, to eradicate a human pathogen from the world for the second time ever. Transition planning represents a serious intent to responsibly bring the world's largest global health effort to a close and to protect and build upon the investment in this effort, where appropriate, to benefit other national and global priorities. Further detailed technical work is now needed, supported by broad and engaged debate, for this undertaking to achieve its full potential.

Monitoring Results in Routine Immunization: Development of Routine Immunization Dashboard in Selected African Countries in the Context of the Polio Eradication Endgame Strategic Plan.

Background: To monitor immunization-system strengthening in the Polio Eradication Endgame Strategic Plan 2013-2018 (PEESP), the Global Polio Eradication Initiative identified 1 indicator: 10% annual improvement in third dose of diphtheria- tetanus-pertussis-containing vaccine (DTP3) coverage in polio high-risk districts of 10 polio focus countries. Methods: A multiagency team, including staff from the African Region, developed a comprehensive list of outcome and process indicators measuring various aspects of the performance of an immunization system. Results: The development and implementation of the dashboard to assess immunization system performance allowed national program managers to monitor the key immunization indicators and stratify by high-risk and non-high-risk districts. Discussion: Although only a single outcome indicator goal (at least 10% annual increase in DTP3 coverage achieved in 80% of high-risk districts) initially existed in the endgame strategy, we successfully added additional outcome indicators (eg, decreasing the number of DTP3-unvaccinated children) as well as program process indicators focusing on cold chain, stock availability, and vaccination sessions to better describe progress on the pathway to raising immunization coverage. Conclusion: When measuring progress toward improving immunization systems, it is helpful to use a comprehensive approach that allows for measuring multiple dimensions of the system.

Protective Effect of Contemporary Pertussis Vaccines: A Systematic Review and Meta-analysis.

BACKGROUND: Acellular pertussis (aP) and whole-cell (wP) pertussis vaccines are presumed to have similar short-term (<3 years after completion of the primary series) efficacy. However, vaccine effect varies between individual pertussis vaccine formulations, and many originally studied formulations are now unavailable. An updated analysis of the short-term protective effect of pertussis vaccines limited to formulations currently on the market in developed countries is needed. METHODS: We conducted a systematic review and meta-analysis of published studies that evaluated pertussis vaccine efficacy or effectiveness within 3 years after completion (>3 doses) of a primary series of a currently available aP or wP vaccine formulation. The primary outcome was based on the World Health Organization (WHO) clinical case definitions for pertussis. Study quality was assessed using the approach developed by the Child Health Epidemiology Research Group. We determined overall effect sizes using random-effects meta-analyses, stratified by vaccine (aP or wP) and study (efficacy or effectiveness) type. RESULTS: Meta-analysis of 2 aP vaccine efficacy studies (assessing the 3-component GlaxoSmithKline and 5-component Sanofi-Pasteur formulations) yielded an overall aP vaccine efficacy of 84% (95% confidence interval [CI], 81%-87%). Meta-analysis of 3 wP vaccine effectiveness studies (assessing the Behringwerke, Pasteur/Mérieux, and SmithKline Beecham formulations) yielded an overall wP vaccine effectiveness of 94% (95% CI, 88%-97%) (bothI(2)= 0%). CONCLUSIONS: Although all contemporary aP and wP formulations protect against pertussis disease, in this meta-analysis the point estimate for short-term protective effect against WHO-defined pertussis in young children was lower for currently available aP vaccines than wP vaccines.

History and evolution of the advisory committee on immunization practices--United States, 1964-2014.

The Advisory Committee on Immunization Practices (ACIP) is chartered as a federal advisory committee to provide expert external advice to CDC and the Secretary of the U.S. Department of Health and Human Services (DHHS) on the use of vaccines in the civilian population of the United States. This report summarizes the evolution of ACIP over the 50 years since its establishment in 1964 by the Surgeon General of the U.S. Public Health Service (USPHS).

A national survey of immunization programs regarding immunization information systems data sharing and use.

OBJECTIVE: To determine and characterize practices regarding data sharing and usage (particularly for research) in immunization information systems (IISs), as well as barriers to using such data for research. DESIGN: We surveyed immunization program managers (IPMs) associated with all 64 Centers for Disease Control and Prevention grantee immunization programs (IPs) between July and September 2012. RESULTS: More than 95% of IPMs (61/64) responded. The top 2 barriers reported by IPMs to using IIS data for research were insufficient time and too few employees, irrespective of whether or not the jurisdiction reported using data for research purposes. Those IPMs who agreed with the statement "Research is part of the mission of an immunization program" were more likely to report using data for research (P = .045). Among those who responded, the most common kind of IIS research conducted involved determinants of vaccination coverage (n = 24/26; 92%). A greater percentage of IPMs in jurisdictions that reported using IIS data for research reported having data-sharing agreements in place. Those IPs that have used IIS data for research were more likely to report online IIS provider enrollment, integration with insurance company records, and integration with hospital records. Alternatively, IPs that did not report using IIS data for research were more likely to have IISs with modules addressing topics such as adverse event reporting, smallpox, and first-responder vaccination. CONCLUSION: Staff size and time were the 2 most cited barriers to conducting research with IIS data. Therefore, focus should also be placed on providing IPs with the resources needed to conduct such research.

Lessons learned from the 2007 to 2009 Haemophilus influenzae type B vaccine shortage: implications for future vaccine shortages and public health preparedness.

OBJECTIVE: To understand immunization programs' experience managing the 2007 to 2009 Haemophilus influenzae type B (Hib) vaccine shortage and identify ways in which the US immunization system can be improved to assist in responses to future shortages of routine vaccines and large-scale public health emergencies. METHODS: An Internet-based survey was conducted from July 2009 to October 2009 among the 64 city, state, and territorial immunization program managers (IPMs). RESULTS: Fifty-eight percent (37 of the 64) of IPMs responded. Forty percent of responding IPMs indicated not having enough Hib vaccine within their Vaccines for Children program to fulfill the temporary 3-dose recommendation issued in December 2007 in response to the Hib vaccine shortage. While 73% of IPMs indicated success in monitoring provider inventory and 68% indicated success in monitoring doses administered during the shortage, fewer than half indicated success in monitoring providers' compliance with shortage-specific recommendations regarding Hib vaccine. Forty-six percent of IPMs used their immunization information system (IIS) to monitor provider compliance with recommendations regarding Hib vaccine use, and of these, nearly 60% reported success in monitoring provider compliance with recommendations compared with 35% of IPMs who did not use their IIS in this way. Forty-two percent of IPMs felt that the Centers for Disease Control and Prevention (CDC) was successful in determining stockpiled vaccine allocations to their program, and 56% felt that the CDC was successful in communicating its rationale for their immunization program's Hib allocation during the shortage. CONCLUSIONS: Experiences from the 2007 to 2009 Hib vaccine shortage offer insights on how the US immunization system and system-wide response to vaccine shortages can be improved. Results from this survey suggest that improving vaccine transfer between jurisdictions and using IIS to track provider compliance with shortage recommendations are 2 ways that can help the US immunization system respond to future vaccine shortages and large-scale public health emergencies like influenza pandemics.

Vaccine-preventable diseases, immunizations, and the Epidemic Intelligence Service.

During 1946-2005, vaccine-preventable diseases were the topic of approximately 20% of all epidemic-assistance investigations by the Centers for Disease Control and Prevention. Both in the United States and abroad, current and former Epidemic Intelligence Service officers have played a critical role in describing the epidemiology of vaccine-preventable diseases, contributing to development of immunization policies, participating in the implementation of immunization programs, and establishing effective means for assessing adverse events following immunization. As newer vaccines are developed and introduced, they will continue to play similar roles and most likely will be involved increasingly in investigations of the factors that affect people's willingness to accept vaccination for themselves or their children.

Newborn dried bloodspot screening: long-term follow-up activities and information system requirements.

PURPOSE: To describe the clinical and public health activities of all entities involved in long-term follow-up of children with conditions identified by newborn dried bloodspot screening, including the requirements for interoperable clinical and public health information systems that will support care from birth through adulthood. METHODS: The Southeastern Newborn Screening Genetics Collaborative (Region 3) convened a workgroup of experts in pediatric care, genetics, and public health, facilitated by the Public Health Informatics Institute (the Institute). The Institute's Collaborative Requirements Development Methodology was used. RESULTS: Three overlapping steps in the long-term follow-up process were examined: needs assessment, ongoing treatment/management, and knowledge generation. In addition, greater definition was given to the roles of Clinical Care Coordinator and Public Health Care Coordinator, as defined by a previous workgroup, and a new role was identified-Care Plan Leader (primary care provider or specialist) who would serve as treatment coordinator and centralize long-term follow-up care provision to minimize gaps in clinical care. CONCLUSION: The outcome of the Region 3 Workgroup's efforts is an expanded notion of long-term follow-up to extend throughout the patient's lifespan, with an emphasis on the coordination of care involving both clinical and public health sectors and on requirements for interoperable clinical and public health information systems.

Stakeholder attitudes toward influenza vaccination policy in the United States.

There is growing interest in simplifying recommendations to vaccinate Americans against influenza. The article discusses interviews with 35 stakeholders from the medical, public health, educational, insurance, and vaccine industry sectors to assess the potential for policy change, and discusses questions posed to the interviewees on current and future influenza vaccination policy and barriers to policy change. About 97% of respondents support the expansion of vaccination for all school-age children, and about 95% support universal vaccination, but there are reservations expressed by the respondents, despite the support for this policy change. Barriers to influenza vaccination recommendations include access, supply, confusing recommendations, and public perceptions. Barriers to universal vaccination include lack of infrastructure, cost, need for education, and vaccine supply. Issues concerning resources and education are challenges that impede policy change. The study findings can be useful to policy makers and practitioners for reviewing U.S. vaccination policy and changes to the policy.

An opportunity to incentivize innovation to increase vaccine safety in the United States by improving vaccine delivery using vaccine patches.

Vaccines represent cost-effective and safe interventions that provide substantial health and economic benefits to individuals and populations. The US vaccine enterprise that supports all aspects of immunization continues to encourage innovation. Despite some limited historical recommendations to create a fund to support investments in vaccine safety, and recent legislation that supports innovation for new vaccines (the 21st Century Cures Act, Public Law 114-255), to date the US lacks financial incentives to fund innovation in vaccine delivery technologies. Building on separate reviews of the US Vaccine Injury Compensation Program (VICP) and the state of development of vaccine patches as an innovative vaccine delivery platform, we suggest an opportunity to allocate some VICP Trust Fund resources to prevent future VICP claims by creating a new incentives fund to support translational studies for improving vaccine delivery technologies. We identify shoulder injury related to vaccine administration (SIRVA) as a test case.

Performance of the United States Vaccine Injury Compensation Program (VICP): 1988-2019.

The United States (US) highly values the individual and societal benefits of vaccination and invests significantly in vaccine development and use as part of its national vaccine enterprise. In 1986, recognizing the small, but non-zero risks associated with vaccines, the US created a mechanism to collect excise taxes on each dose of vaccine to fund a national Vaccine Injury Compensation Program (VICP). The VICP includes a system for those claiming serious injuries from vaccines to seek compensation, and a process to pay individuals with legitimate claims and their legal counsel. Given the maturity of the VICP, we review experience with the vaccines and injuries covered, claims, and economics of the fund. Our review shows the excellent safety track record of vaccines, provides some evidence of injuries related specifically to vaccine delivery, and discusses the financial health of the fund.

Adherence to Timely Vaccinations in the United States.

OBJECTIVES: To estimate (1) the proportion of children not adhering to the Advisory Committee on Immunization Practices (ACIP) recommended early childhood immunization schedule and (2) associations between schedule adherence, sociodemographic characteristics, and up-to-date immunization status by 19 to 35 months of age. METHODS: We used 2014 National Immunization Survey provider-verified vaccination data to classify vaccination patterns as "recommended" (ie, in line with ACIP dose- and age-specific recommendations), "alternate" (ie, in line with either limiting the number of shots per visit or skipping at least 1 vaccine series), or "unknown or unclassifiable" (ie, not in line with ACIP recommendations or clearly limiting shots per visit or vaccine series). We evaluated the association between vaccination patterns and up-to-date status for all ACIP-recommended vaccinations (including rotavirus and hepatitis A vaccines) using Poisson regression. RESULTS: The majority of children's patterns were classified as "recommended" (63%), with 23% and 14% following alternate or unknown or unclassifiable patterns, respectively; 58% of children were up-to-date with all ACIP-recommended immunizations by 19 to 35 months. Not being up-to-date was associated with alternate (prevalence ratio = 4.2, 95% confidence interval: 3.9-4.5) and unknown or unclassifiable (prevalence ratio = 2.4, 95% confidence interval: 2.2-2.7) patterns. CONCLUSIONS: High vaccine coverage by 19 to 35 months of age may miss nonadherence to the recommended immunization schedule in the first 18 months of life, leaving children vulnerable to preventable diseases. With more than one-third of US children not following the ACIP schedule, targeted interventions are needed to minimize vaccine delays and disease susceptibility.

Newborn dried bloodspot screening: mapping the clinical and public health components and activities.

PURPOSE: To define components and activities of the entire Newborn Dried Bloodspot Screening process, highlighting long-term follow-up-both clinical and public health-as a basis for defining requirements for information systems to support the process. METHODS: Convene a workgroup of experts involved in various aspects of Newborn Dried Bloodspot Screening and conduct an analysis of the components and activities involved, applying Business Process Analysis, part of a collaborative requirements definition process conceived by the Public Health Informatics Institute. RESULTS: The Newborn Dried Bloodspot Screening workgroup identified four primary business processes: screening, confirmatory/diagnostic testing, transition to long-term follow-up, and intervention management (long-term follow-up). Long-term follow-up includes care coordination/ongoing treatment, continuous quality improvement, knowledge generation, and knowledge management and dissemination. In addition, the Newborn Dried Bloodspot Screening workgroup identified public health care coordination as a new and important role to assure successful long-term follow-up. This role is defined in some detail. CONCLUSION: Successful newborn screening systems rely on effective partnerships to ensure that there is appropriate screening, diagnosis, and follow-up. Coordinating care across multiple settings and service providers, ensuring continuity of care over time, and generating new knowledge about heritable disorders requires information systems that can fully support the process. Developing such information systems requires a clear understanding of the Newborn Dried Bloodspot Screening process and documentation of the roles and responsibilities for all involved. Business process analysis can be applied to Newborn Dried Bloodspot Screening and other child health programs to help achieve that outcome.

Support for universal childhood vaccination against influenza among private pediatric clinics and public health departments in Georgia.

Recently, it has been recommended that all persons 6 months to 18 years be vaccinated annually against influenza. To assess support for this universal recommendation leading up to its implementation, a cross-sectional survey of healthcare workers at private pediatric clinics (N = 44) and public health departments (N = 75) was conducted. The survey, conducted in the state of Georgia during 2005-2006, asked about (a) support for universal childhood vaccination against influenza, (b) general and influenza-specific immunization practices in 2004-2005, and (c) types of assistance needed to implement a universal childhood recommendation. Our response rate was 70 percent for private clinics and 71 percent for public health departments. The majority of providers supported universal childhood vaccination against influenza; agreement was especially pronounced at public health departments. Public health departments employed more nurses and were more likely to have a policy of vaccinating parents along with their children; private clinics were more likely to use patient reminders or add extra hours during the influenza vaccination season. Respondents from both types of clinics indicated they would need multiple forms of assistance to implement a universal recommendation for childhood vaccination against influenza. Given the strong support for universal vaccination among healthcare workers at public health departments, these facilities may be instrumental for reaching the large number of children recently added to the recommendations. However, these facilities will need multiple forms of assistance.

The Global Vaccine Action Plan - insights into its utility, application, and ways to strengthen future plans.

BACKGROUND: The pace of global progress must increase if the Global Vaccine Action Plan (GVAP) goals are to be achieved by 2020. We administered a two-phase survey to key immunization stakeholders to assess the utility and application of GVAP, including how it has impacted country immunization programs, and to find ways to strengthen the next 10-year plan. METHODS: For the Phase I survey, an online questionnaire was sent to global immunization stakeholders in summer 2017. The Phase II survey was sent to regional and national immunization stakeholders in summer 2018, including WHO Regional Advisors on Immunization, Expanded Programme on Immunization managers, and WHO and UNICEF country representatives from 20 countries. Countries were selected based on improvements (10) versus decreases (10) in DTP3 coverage from 2010 to 2016. RESULTS: Global immunization stakeholders (n = 38) cite global progress in improving vaccine delivery (88%) and engaging civil society organizations as advocates for vaccines (83%). Among regional and national immunization stakeholders (n = 58), 70% indicated reaching mobile and underserved populations with vaccination activities as a major challenge. The top ranked activities for helping country programs achieve progress toward GVAP goals include improved monitoring of vaccination coverage and upgrading disease surveillance systems. Most respondents (96%) indicated GVAP as useful for determining immunization priorities and 95% were supportive of a post-2020 GVAP strategy. CONCLUSIONS: Immunization stakeholders see GVAP as a useful tool, and there is cause for excitement as the global immunization community looks toward the next decade of vaccines. The next 10-year plan should attempt to increase political will, align immunization activities with other health system agendas, and address important issues like reaching mobile/migrant populations and improving data reporting systems.

Development of a US trust measure to assess and monitor parental confidence in the vaccine system.

OBJECTIVE: To develop a Vaccine Confidence Index (VCI) that is capable of detecting variations in parental confidence towards childhood immunizations centered on trust and concern issues that impact vaccine confidence. METHODS: We used a web-based national poll of 893 parents of children <7 years in 2016 to assess the measures created for the Emory VCI (EVCI). EVCI measures were developed using constructs related to vaccine confidence identified by the U.S. National Vaccine Advisory Committee (i.e., "Information Environment", "Trust", "Healthcare Provider", "Attitudes and Beliefs", and "Social Norms"). Reliability for EVCI was assessed using Cronbach's alpha. Using the variables related to each of the constructs, we calculated an overall EVCI score that was then assessed against self-reported childhood vaccine receipt using chi-square and the Cochrane-Armitage trend tests. RESULTS: Respondents' EVCI scores could range from 0 to 24, and the full range of values was observed in this sample (Mean = 17.5 (SD 4.8)). EVCI scores were significantly different (p ≤ 0.006 for all comparisons) between parents who indicated their child(ren) received routinely recommended vaccines compared with parents who indicated they had delayed or declined recommended immunizations. There was also a significant, consistent association between higher EVCI scores and greater reported vaccine receipt. CONCLUSIONS: We developed EVCI to reliably measure parental vaccine confidence, with individuals' scores linked to parental vaccine-related attitudes, intentions, and behaviors. As such, EVCI may be a useful tool for future monitoring of both population and individual confidence in childhood immunization.