The Role of Measles Elimination in Development of a National Immunization Program

Orenstein, Walter A. MD

Disclosures

Pediatr Infect Dis J. 2006;25(12):1093-1101. 

In This Article

Measles Resurgence 1989-1991

In 1989, another major resurgence of measles occurred with more than 55,000 cases reported between 1989 and 1991, an average of more than 18,000 cases a year compared with approximately 3000 cases annually earlier in the 1980s (Fig. 1).[25,26,27] The resurgence was particularly severe accounting for more than 11,000 hospitalizations and 123 deaths. The cases were predominantly unvaccinated preschoolers but, particularly early in the outbreak, there were many college students affected who had received one dose of vaccine previously (Fig. 6). The 1989 college outbreaks came at a time when recommendations called for revaccination during an outbreak setting. Responding to the college outbreaks was costly, regular budgets did not anticipate the costs of such responses and mounting emergency campaigns was frustrating and difficult.

Age-specific measles incidence (percent increase) in the United States, 1981 through 1989 and 1990. (All data, including unpublished 1990 provisional data through week 52, provided by the Centers for Disease Control and Prevention, Atlanta, GA.) (Reprinted from The National Vaccine Advisory Committee. JAMA. 1991;266:1547-1552. Copyright © 2006, American Medical Association.)

Because >95% of children entering school had received a dose of measles vaccine, preventing the school-aged outbreaks required a second dose of vaccine. Waning immunity with increasing time since vaccination was not a significant cause of vaccine failure.[28] Instead, the major problem was primary vaccine failure-the failure to respond to the first dose. Questions were raised about whether measles was so contagious that it could persist among the 2% to 5% of persons who failed to mount an initial immune response to a single dose.[29] There was much debate, particularly among persons in public health, of the need for a second dose because of the cost of implementation. Additionally, the first dose was not being well implemented, particularly in preschool children, many of whom did not receive their vaccine until just before school entry. Perhaps measles outbreaks would not occur if higher first-dose coverage were achieved in young children. Before going to the expense of adding a second dose to the schedule, some felt more resources should be devoted to improving first-dose coverage and seeing if that was enough to terminate measles transmission.

A small meeting in New York State broke the log jam on moving to a routine 2-dose schedule. College outbreaks in the state captured the attention of the Health Commissioner, David Axelrod. He called together academic infectious disease specialists, led by Saul Krugman and Martha Lepow, state and county health officials and representatives of the CDC to decide how best to address the problem. During the meeting, consultants agreed that the major problem with measles in colleges was failure to make an adequate immune response after a single dose of measles vaccine rather than waning immunity. Led by Saul Krugman, the academic pediatric infectious disease experts had already come to the conclusion that a second dose of measles vaccine would be necessary if measles elimination was the goal. However, the public sector representatives resisted, primarily because of cost considerations. After spirited discussion, the group did not reach unanimity about whether to recommend a routine 2-dose schedule. Near the end of the meeting, Dr. Axelrod came in to hear the conclusions and said emphatically, don't tell me what it costs, tell me what is the right thing to do. He pointed out that New York State should be preventing outbreaks, not trying to control them, and declared that New York State would implement a 2-dose schedule even if it were the only state. Public sector opposition to a 2-dose schedule rapidly melted.

In 1989, both the Advisory Committee on Immunization Practices (ACIP) and the Committee on Infectious Diseases of American Academy of Pediatrics recommended a second dose.[29,30]

Other political groups took an interest in immunization and the Omnibus Reconciliation Act of 1986, which established the Childhood Vaccine Injury Compensation Program, also established a new program, the National Vaccine Program (NVP), and a new committee, the National Vaccine Advisory Committee (NVAC).[3] The role of the NVP was to coordinate the federal government's efforts in vaccines and immunization. The National Vaccine Advisory Committee had no track record and was looking for an issue to make a mark. The measles resurgence was viewed as an indicator of a whole immunization system that was in trouble. A response to the measles resurgence offered the opportunity to design the immunization program of the future.

The diagnosis was clear. The major cause of the resurgence was a failure to vaccinate preschool children at the recommended age, 12 to 15 months.[31] Health services research identified the prominent factor to be the healthcare system failing to take advantage of the many opportunities it had to vaccinate children.[3,32] These missed opportunities occurred in physicians' offices and clinics where all vaccines for which children were eligible were not being provided simultaneously, where invalid contraindications were used to exclude otherwise eligible children, where immunizations were provided only in well child visits when there were other visits during which there were no contraindications and where children were referred out of physicians' offices to public clinics for free vaccines because the children's parents could not afford the costs. Missed opportunities were also occurring in public programs targeted to the poor such as the WIC program. These programs were accessing some of the children at highest risk of underimmunization but were not assuring their clients were vaccinated. The public sector infrastructure was in disarray with parents having to wait weeks to months for appointments.[33] During the resurgence, lines formed around clinics with waits of hours to get children immunized against measles.

In 1991, the NVAC issued a measles White Paper laying out the blueprint for much of the current immunization program.[31] Selected recommendations included: (1) provide funds through the 317 grant program to pay for vaccine delivery (never covered previously); (2) eliminate underinsurance for vaccines. The NVAC recognized that cost of vaccines was a barrier for persons with insurance whose insurance did not cover vaccination. Trying to solve the vaccine-financing issue played a major role in developments later in the 1990s; (3) Support the development of immunization coalitions of partner groups at state and local levels to build the political base for action, including meeting resource needs and implementation of key policies; (4) develop standards for immunization practices and encourage adoption of practices that would lead to high coverage rates; (5) assure clients of major public programs such as WIC are immunized;.(6) foster collaboration between the public sector and professional medical societies; (7) measure immunization coverage of preschool children and explore means of measurement at the state and local level; and (8) support health services research on immunization delivery and research on measles.

Also, in the early 1990s, the Bush Administration was looking for ways of responding to the resurgence. Secretary of Health and Human Services, Louis Sullivan, offered to lead visits to areas suffering from, or at risk for, measles. We selected 6 cities for his visits and used the opportunity to work with these cities to develop immunization action plans (IAPs) to achieve 90% immunization coverage among 2-year-old children.[34] These IAPs listed steps that could be taken with current resources, other steps that required additional resources and estimates of those resource needs. The final plans were presented to the Secretary at his visit and in front of local media. The IAP process in the 6 cities was so useful that all states and major urban areas were required to develop IAPs. Importantly, this provided budget estimates of the overall national need, estimates that were to prove useful when the Clinton Administration took office and made immunization one of their highest public health priorities.

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