Centers for Disease Control and PreventionNational Center for Immunization and Respiratory Diseases

Centers for Disease Control and PreventionNational Center for Immunization and Respiratory Diseases

Centers for Disease Control and PreventionNational Center for Immunization and Respiratory Diseases

Centers for Disease Control and PreventionNational Center for Immunization and Respiratory Diseases

Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or extended for use in printing or any use by other CDC CIOs or any external audiences.

November 4, 2017

Shannon Stokley, DrPH

Immunization Services Division

Centers for Disease Control and Prevention

SmallpoxPolio

DiphtheriaPertussisTetanusMeasles

1964 (6)Polio

DiphtheriaPertussisTetanusMeaslesRubellaMumps

1985 (7)

Polio

Diphtheria

Pertussis

Tetanus

Measles

Rubella

Mumps

Hib (infant)

HepB

HepA

Varicella

Pneumococcal

Influenza

Meningococcal

Rotavirus

HPV

PolioDiphtheriaPertussisTetanusMeaslesRubellaMumps

Hib (infant)HepB

Varicella

1995 (10)2017 (16)

Polio

Diphtheria

Pertussis

Tetanus

Measles

Rubella

Mumps

Hib (infant)

HepB

HepA

Varicella

Pneumococcal

Influenza

Meningococcal

Rotavirus

HPV

Number of Diseases Prevented by Vaccines Included in the Routine Child/Adolescent Immunization Schedule

Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases

Disease

20th Century

Annual Morbidity†

2015

Reported Cases † †

Percent

Decrease

Smallpox 29,005 0 100%

Diphtheria 21,053 0 100%

Measles 530,217 189 > 99%

Mumps 162,344 1,057 99%

Pertussis 200,752 18,166 91%

Polio (paralytic) 16,316 0 100%

Rubella 47,745 5 > 99%

Congenital Rubella Syndrome 152 1 99%

Tetanus 580 25 96%

Haemophilus influenzae 20,000 23* > 99%

† JAMA. 2007;298(18):2155-2163† † CDC. MMWR January 8, 2016/ 64(52);ND-923 – ND-940. (MMWR 2015 week 52 provisional data)

* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 10 cases of Hib are estimated to

have occurred among the 211 reports of Hi (< 5 years of age) with unknown serotype.

CDC estimates that vaccination of children born between 1994 and 2016:

Prevent 381 million illnesses

Prevent 24.5 million hospitalizations

Help avoid 855,000 early deaths

Save nearly $360 billion in direct costs and $1.65 trillion in total society costs

Every dollar spent in childhood vaccination ultimately saves $10.10.

Childhood Immunization Provides Big SavingsVaccines for Children: 23 years of protecting America’s children

Updated March 2017 from previous article: Benefits from Immunization During the Vaccines for Children Program Era – United States, 1994-2013. MMWR. 25 April 2014

Vaccine Coverage among Children 19-35 Months, National Immunization Survey, United States, 1994-2016

0

10

20

30

40

50

60

70

80

90

1001

99

4

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

20

13

20

14

20

15

20

16

Pe

rce

nt

Vac

cin

ate

d

Year

MMR (1+)

DTP/DTaP (3+)

Polio (3+)

Hib (3+)

HepB (3+)

Varicella (1+)

PCV (4+)

Rotavirus

HepA (2+)

3+HepB

1+ Varicella4+ PCV 2+ HepA

Rotavirus

<1% of toddlers had received no vaccines

Completion of vaccination series by age, National Immunization Survey-Kindergarten (Oct, 2013 – Mar, 2014)

Smith et al. Vaccine. 2017;35:5346-5351.

0

10

20

30

40

50

60

70

80

90

100

2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Perc

ent

Median and Range* of Measles, Mumps, and Rubella Vaccine (MMR) Coverage, and Exemptions from Any Required Vaccination† among Kindergartners, United States, 2011-12 to 2016-17 School Years

Median MMR Coverage Median Exemption from Any Required Vaccination

Source: School Vaccination Assessment Program, 2011-12, 2012-13, 2013-14, 2014-15, 2015-16, and 2016-17; Available from: https://www.cdc.gov/vaccines/vaxview/index.html.Abbreviations: MMR = measles, mumps, and rubella vaccine.

53.8 54.7

43.1

55.8

86.589.9 90.5 88.6

0

20

40

60

80

100

DTaP Poliovirus MMR Varicella

Exempt Not Exempt

Vaccination coverage by exemption status, National Immunization Survey-Kindergarten (Oct, 2013 – Mar 2014)

Smith et al. Vaccine. 2017;35:5346-5351.

1.9% requested an exemption

95.6% of exempt children had receivedat least 1 dose of vaccine

Children with an exemption receivedan average of 21.8 vaccine doses

Children without an exemption receivedan average of 28.2 vaccine doses

Represents children who are attending kindergarten but do not have documentation of being vaccinated or requesting an exemption

Measles vaccination:– 90.9% vaccinated– 1.1% requested an exemption and unvaccinated– 0.3% provisionally enrolled/grace period and unvaccinated– 7.7% no documentation of vaccination or exemption

Vaccination coverage gap, National Immunization Survey-Kindergarten (Oct, 2013 – Mar 2014)

Smith et al. Vaccine. 2017;35:5346-5351.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

D C E B P J U O Q T A F G R K I H N L M S

(Wei

ghte

d)

Perc

ent

State

Estimated Percent of Kindergartners with Documented Vaccination for MMR (MMR UTD), Exempt from MMR Vaccination (MMR Exempt), or in the Vaccination-Exemption Gap (VEG)

- Selected States, 2016-17 School Year

Vaccinated Exempt No documentation

10 Years of HPV Vaccination

0

10

20

30

40

50

60

70

80

90

100

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Pe

rce

nt

Vac

cin

ate

d

Survey Year

Tdap

MCV4

1 HPV girls

3 HPV girls

1 HPV boys

3 HPV boys

1 HPV girls &boys

88.0

82.2

65.1

56.0

43.0

31.5

60.4

*Source Walker, et al. MMWR; August 25, 2017 / 66(33);874–882

Number of HPV-Attributable Cancers Averted over 100 Years of 9-Valent HPV Vaccination Program

Estimates calculated using published model (Chesson et al, Hum Vaccin Immunother 2016), with modified coverage assumptions. Coverage levels shown (39.7%, 21.6%, and 80%) refer to coverage among ages 13-17. For females, the annual probability of vaccination in the current coverage scenario was modeled as 20.9% for age 12, 8.9% for ages 13 to 18, and 0.89% for ages 19 to 26. For males, these values were 10.5%, 4.4%, and 0.44% (through age 21), respectively. In the 80% coverage scenario, the annual probability of vaccination was 73.8% for age 12, 8.9% for ages 13 to 18, and 0.89% for those 19 and older (through age 21 for men and age 26 for women).

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

HPV cancers averted total (excluding herd immunity) HPV cancers averted total

Nu

mb

er o

f H

PV

-att

rib

uta

ble

can

cers

ave

rted

2014 coverage (Females 39.7%, Males 21.6%)

Higher male and female coverage (80%)

709,000

1.23 million

Total US population

1.56 million

1.27 million

How do we Communicate with Parents about Vaccines?

Examples of How We Use a Risk Communication Approach

Show empathy--we know parents want to protect their kids

Acknowledge both benefits and risks of vaccines

Cite facts and data whenever possible

Talk about what we don’t know

Give concrete action steps

Frame the Conversation Positively

Source: Opel et al. Pediatrics 2013; 132:1037

Observational study included 93 discussions about vaccines

74% of providers used a presumptive approach– “He’s due for three shots today”

26% used a participatory approach– “What would you like to do about shots?”

Bottom line: Presumptive approach had less parental resistance to immunizations (26% versus 83%)

HPV Vaccination: Announcement vs. Conversation

Will a “conversation” versus an “announcement” of vaccines recommended on the adolescent platform impact uptake?

Brewer NT, Hall ME, Malo TL, et al. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial. Pediatrics. 2017;139(1):e20161764

Structure of “announcement”

Child is due for 3 vaccines to be given today:

• mentioning the child’s age; • announcing the child is due for 3 vaccines

recommended for children this age, • placing HPV vaccine in the middle of list; and• Saying they will vaccinate today

Brewer NT, Hall ME, Malo TL, et al. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial. Pediatrics. 2017;139(1):e20161764

6.4

9.5

11.5

14.9

8.4

11.5

0

2

4

6

8

10

12

14

16

3 months 6 months

Pe

rce

nta

ge P

oin

t C

han

ge in

Co

vera

ge

Time Post-training

Control Announcement Conversation

“Announcement” improved HPV vaccine acceptance, compared to “conversation”

Brewer NT, Hall ME, Malo TL, et al. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial. Pediatrics. 2017;139(1):e20161764

Motivational Interviewing Techniques for Difficult Vaccine Discussions

Slide courtesy of: Sean O’Leary, MD, MPH, NFID Clinical Vaccinology Course ,Spring 2015

For patients who are unsure or resistant, a closed-ended question following a recommendation can lead to less productive conversations

Motivational interviewing (MI) is a patient-centered, guiding communication style for enhancing a person’s own motivation for change or behavioral activation

MI includes:– Open-ended questions – Affirmations – Reflection – Summary

Some Parents Need Reassurance

Many parents simply accept this bundled recommendation

Some parents may be interested in vaccinating, yet still have questions. Interpret a question asthey need additional reassurance from YOU, the clinician they trust with their child’s health care

Ask parents about their main concern (be sure you are addressing their real concern)

Unpublished CDC data, 2013.

Want to See Experts Answering Questions?

www.vaccinateyourbaby.org/faq

#HowIRecommend

Provider Resources for Vaccine Conversations with Parents

Developed with partners AAP and AAFP

Based on formative research and reviewed regularly

Uses risk communication principles

Provides information for conversations on vaccines, vaccine safety, and vaccine preventable diseases

Includes supplemental resources for parents

www.cdc.gov/vaccines/conversations

Resources for Parents

www.cdc.gov/vaccines/partners/childhood/multimedia.html

Resources for Parents: If you Choose not to Vaccinate

For parents who are considering or have decided to delay or refuse recommended vaccines

Discusses:– Steps to take before or during an outbreak to

help protect their family and community– The importance of notifying healthcare

professionals that a child is not fully vaccinated

– Considerations when travelling

Main message: this is not a risk-free choice

For more information, contact CDC1-800-CDC-INFO (232-4636)TTY: 1-888-232-6348 www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or extended for use in printing or any use by other CDC CIOs or any external audiences.

Thank you!