Epidemiologic Reviews Advance Access originally published online on June 16, 2006
Epidemiologic Reviews 2006 28(1):1-2; doi:10.1093/epirev/mxj011
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EDITORIAL |
Editorial: Vaccines and Public Health
Health workers have known for decades that infant mortality, among all health indices, is an excellent proxy indicator for gauging the socioeconomic and affluence levels of a country. Give me a country's infant mortality rate, and I will place that country in the correct position on the "affluence scale" of nations. Can we make the same observation about vaccination rates and policies? Do these rates and policies give us some indication of the socioeconomic standing of a country, a region within a country, or a racial/ethnic group within a region? Moreover, in this age, we may want to ask another question of immense consequence: Does vaccination status point to the local, state, or national level of preparedness to respond effectively to unforeseen major disasters, natural or intentional?
In this 2006 thematic issue of Epidemiologic Reviews on vaccines and public health, we present reviews on important facets of some vaccines against preventable diseases and of vaccination policies. The reviews raise issues such as whether to target high-risk groups or adopt universal approaches, emphasizing vaccination of children, immunization coverage and vaccine distribution, and the challenges of incorporating new vaccines into ongoing, proven intervention strategies.
We lead off the issue with a comprehensive review of the long-standing practice of vaccinating the armed forces, which was pivotal in protecting the men and women in this well-defined population of more than 2 million for centuries (1). This review shows that US military medicine has contributed to the development of vaccines as well as policies. In addition, it demonstrates that vaccinating this special population protects not only its members but also the communities in which they perform their duties.
Of great interest are the concerns about the role of screening for cervical cancer in light of the impending use of a vaccine against human papillomavirus. The US Food and Drug Administration will most likely license the vaccine(s) in June 2006, and this action will be a major step toward preventing cervical cancer, among other conditions (2). Presentations at the Advisory Committee on Immunization Practices indicated a very high degree of vaccine efficacy. We may find that a two-pronged approach of both screening and vaccination will be the recommended course of action. The current absence of data on the long-term effectiveness and potential consequences of the vaccines stimulated Dasbach et al. (3) to review and analyze several mathematical models designed to project these long-term factors.
The burden of influenza on public health is enormous (4). The rate of infection is highest in children, about one third of whom suffer from this condition each year, and influenza-associated mortality is highest in people aged 65 years or older. The load on the health care system is also substantial in terms of hospitalizations and outpatient and emergency room visits. The resulting loss of productivity from deaths and absenteeism from work and school places an economic burden of billions of dollars on society each year. Mair et al. (4), among others, have argued for a universal influenza vaccination program.
A series of reviews addressing a few aspects of influenza immunization point to the prudence of reducing the burden of this widespread disease in the general population. To begin with, measuring the extent of immunization coverage would be helpful. In one of the reviews, Salmon et al. (5) evaluate the various approaches to estimating immunization coverage among preschool children, including the National Immunization Survey. For example, Coleman et al. combined epidemiology and economics to address the issue of "whether community-based, universal childhood vaccination policies would be more efficacious and cost-effective than strategies targeted toward persons at high risk of disease complications" (6, p. 41). Even targeting high-risk groups has its problems. For instance, national programs targeting only indigenous people result in little success. On the other hand, "geographic targeting of all persons in certain regions with high disease rates has been successful, as has targeting of indigenous populations in regions where they constitute larger proportions of the population" (7, p. 71).
Another example, targeting vaccination against influenza toward pregnant women, has not been successful—the vaccination rate has been less than 10 percent in spite of the proven safety of the vaccine (8). Vaccination coverage of high-risk groups remains low despite efforts to reach these groups. Ompad et al. (9) review strategies to distribute influenza vaccine to such groups to understand how to achieve successful interventions. Identifying successful interventions, such as mailings, phone calls, and patient and staff education, might help reduce the health disparities in the United States and reach the Healthy People 2010 goals.
The geographic divide between developed and developing countries manifests itself clearly in efforts to prevent congenital rubella syndrome (10). Routine implementation of rubella immunization in young children in developing countries is commendable. However, immunization rates must be high or accompany immunization of seronegative women of childbearing age. Failure to do so might result in "a paradoxical increase in CRS [congenital rubella syndrome] as the burden of illness is shifted to an older age group" (10, p. 81).
We include three reviews showing the effectiveness of vaccination against hepatitis A and hepatitis B infections. By 2004, after the Food and Drug Administration licensed hepatitis A vaccine in the mid-1990s, and especially after childhood vaccination became a priority in 1999, the infection rate had fallen by almost 80 percent to a record low of about 2/100,000 (11).
For hepatitis B vaccination, the results are equally successful. For example, implementation of universal infant hepatitis B immunization in the United States resulted in a more than 70 percent decline in acute hepatitis B infections (12). In Taiwan, seroprevalence data on children born before and after implementation of the national immunization program showed about 80 percent effectiveness. Both acute and chronic liver conditions have declined substantially (13).
Immunization programs and policies anywhere in the world are complex. In the United States, vaccination policies involve an amorphous mix of collaboration among such entities as government, industry, academic institutions, and professional societies. Despite the impressive successes in the United States and elsewhere, "the system faces numerous challenges, including vaccine supply, cost, and safety; adult immunization; vaccine research and development; and biopreparedness" (14, p. 599).
REFERENCES
- Grabenstein JD, Pittman PR, Greenwood JT, et al. (2006) Immunization to protect the US Armed Forces: heritage, current practice, and prospects. Epidemiol Rev 28:3–26.
[Abstract/Free Full Text] - Steinbrook R. (2006) The potential of human papillomavirus vaccines. N Engl J Med 354:1109–12.
[Free Full Text] - Dasbach EJ, Elbasha EH, Insinga RP. (2006) Mathematical models for predicting the epidemiologic and economic impact of vaccination against human papillomavirus infection and disease. Epidemiol Rev 28:88–100.
[Abstract/Free Full Text] - Mair M, Grow RW, Mair JS, et al. (2006) Universal influenza vaccination: the time to act is now. Biosecur Bioterror 4:20–40.[CrossRef][ISI][Medline]
- Salmon DA, Smith PJ, Navar AM, et al. (2006) Measuring immunization coverage among preschool children: past, present, and future opportunities. Epidemiol Rev 28:27–40.
[Abstract/Free Full Text] - Coleman MS, Washington ML, Orenstein WA, et al. (2006) Interdisciplinary epidemiologic and economic research needed to support a universal childhood influenza vaccination policy. Epidemiol Rev 28:41–6.
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[Abstract/Free Full Text] - Ompad DC, Galea S, Vlahov D. (2006) Distribution of influenza vaccine to high-risk groups. Epidemiol Rev 28:54–70.
[Abstract/Free Full Text] - Robinson JL, Lee BE, Preiksaitis JK, et al. (2006) Prevention of congenital rubella syndrome—what makes sense in 2006 ? Epidemiol Rev 28:81–7.
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[Abstract/Free Full Text] - Chien YC, Jan CF, Kuo HS, et al. (2006) Nationwide hepatitis B vaccination program in Taiwan: effectiveness in the 20 years after it was launched. Epidemiol Rev 28:126–35.
[Abstract/Free Full Text] - Orenstein WA, Douglas RG, Rodewald LE, et al. (2005) Immunizations in the United States: successes, structure, and stress. Health Aff (Millwood) 24:599–610.
[Abstract/Free Full Text]
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