Cover Story -- September 2004
An uninvited boarder moved into Susan Todd's Graham, Texas, home in 1952. The intruder stole the young girl's toys and blankets and almost took her life.
In the 1950s, the deadly vagabond was an unwelcome visitor to almost every community in the country. The fear was tangible. According to the U.S. Centers for Disease Control and Prevention (CDC), the scourge of the poliomyelitis virus struck an average of 16,316 Americans annually during the 20th century. More than 100,000 cases of polio occurred in the United States between 1952 and 1954, alone.
In Graham, Ms. Todd, her brother, and their next door neighbor were among polio's victims. The neighbor died, but thankfully Ms. Todd and her brother, who were 3 and 2 at the time, recovered. With help from a skilled orthopedic surgeon, they have led normal lives. Her brother, whose legs had been paralyzed, even played high school basketball and college baseball.
The illness left its impact on the family and community.
"After we were sick, they ended up burning all of our toys. They took all of our toys and blankets away," said Ms. Todd, a former Texas Medical Association Alliance president. "Neighbors were afraid for a while to be near us because people really didn't understand how polio was communicated back and forth."
But the intruder was not long for this world. Within three years of Ms. Todd's illness, children across America began receiving the polio vaccine, and the disease has been eradicated from the United States and much of the rest of the world. There has not been a case of naturally occurring polio transmission in the United States since 1979.
"The blessing is that polio is something I never had to worry about with my kids," Ms. Todd said.
In fact, nearly a dozen diseases that sickened or killed hundreds of thousands of Americans each year during the past century have been virtually eradicated here, thanks to the development of vaccines.
A Success Story
TMA President Bohn D. Allen, MD, says immunization is without question one of the biggest success stories of 20th century medicine, and "one of the single most important preventive measures we can take."
The science of vaccination is more than 200 years old. It began in 1796 when British physician Edward Jenner noted that dairymaids who contracted cowpox, a relatively mild illness, seemed to be immune to smallpox. Dr. Jenner inoculated an 8-year-old boy with diseased matter from a dairymaid with cowpox and 48 days later injected smallpox matter into the boy. The boy did not contract smallpox.
Dr. Jenner's discovery was followed by the introduction of vaccines against rabies, typhoid, cholera, and plague in the late 19th century. Today, there are vaccines against more than 25 infectious diseases, as well as therapeutic vaccines to help fight various forms of cancer.
The results have been staggering. According to CDC, smallpox became so rare in the United States that routine vaccination was discontinued in 1971, and smallpox vaccine was taken off the market in 1983. The last known case in the world was reported in Somalia in 1977.
Meanwhile, polio was declared eradicated in the Americas in 1994. Diphtheria, measles, mumps, rubella, and tetanus have become almost nonexistent in the United States. During the last century, an average of more than 500,000 Americans contracted measles annually. CDC reported only 42 cases of measles in the United States in 2003. Similarly, an average of more than 175,885 Americans caught diphtheria annually. CDC statistics show only one case in 2003. Texas numbers are similar.
Texas Department of Health (TDH) statistics show measles peaked at 88,000 cases in 1958. No cases were reported in 2003. The state also has seen 100-percent reductions in rubella, diphtheria, and polio, and had only one tetanus case in 2003. Mumps cases dropped from 32,939 in 1950 to 18 last year.
Rita Espinoza, MPH, an epidemiologist with the TDH Bureau of Immunization and Pharmacy Support, says the few measles cases seen in Texas in recent years originated in Mexico or elsewhere.
Letting Our Guard Down
Despite vaccines' dramatic impact in improving public health, however, not all Americans are reaping the benefits. According to the U.S. National Immunization Survey, immunization rates among small children are as low as 65 percent in some states.
Texas currently is tied for 41st nationally in the percentage of children between 19 and 35 months who have received the four recommended doses of the diphtheria-tetanus-pertussis vaccine (DTaP), three doses of polio vaccine, and one dose of measles-mumps-rubella (MMR) vaccine. In 2003, only 78.1 percent of Texas children under age 3 had received all doses of those vaccines. In 2002, only 71.3 percent of Texas children under age 3 were fully immunized, placing Texas 45th in the national ranking.
Those low immunization rates have allowed some diseases to reemerge. Pertussis, for example, was all but eradicated in the United States in the mid-1970s but has been increasing steadily over the past two decades. Between 1996 and 2000, an average of 7,000 cases of pertussis were confirmed in the United States annually, according to CDC.
The reasons for Texas' low ranking seem to be myriad. Madisonville family physician Andrew Eisenberg, MD, chair of TMA's Council on Public Health, says the complexity of the immunization schedule, lack of insurance and access to care, mistrust of the medical community among many minority populations, and the state's size and high birth rate are contributing factors.
"We have the fastest growth rate in terms of births of any state in the country," he said. "There are thousands of babies born every day in Texas. That's a lot of kids to vaccinate."
Also, parents often forget about vaccinations or skip well-child checkups. Many take their children to the doctor only when they are sick. Dr. Eisenberg says physicians can take those opportunities to catch a child up on vaccinations.
"I've heard arguments from physicians and others that you can't immunize patients if they've got a cold or you can't give too many shots at once," he said. "A lot of that is just misinformation. There are very few contraindications to most vaccines." (For more on vaccine contraindications, see the TMA Web site at 226.html .)
Ms. Espinoza says despite its low ranking in the National Immunization Survey, Texas actually does a pretty good job getting kids most of the recommended doses of vaccines. She says failure to follow up on the fourth dose of DTaP lowers the state's ranking.
"If you look at how many have received that first measles and three polio [vaccinations], those estimates are fairly high, 80 to 90 percent," she said. "So it's really children missing the fourth DTaP ."
According to data compiled from multiple sources by the TMA Public Health Department, most of the states in the top 10 in childhood immunizations are small and have some form of universal vaccine-purchase system in which the state buys vaccines for all children, including those with private insurance. They also have immunization registries with implied consent to include each child's immunization record, and they have no opportunity for parents to opt out and no provision to bypass vaccinations for philosophical reasons.
Texas has none of those, and its immunization registry, ImmTrac, has not been very effective. Parents must opt in at the time of birth in order for a child's records to be included.
The state also has a new conscientious objection law. In 2003, Texas vaccination opponents slipped a provision allowing parents to claim conscientious objection to vaccines normally required for public school children into legislation to reorganize state health and human services agencies.
Parents now can request up to five affidavits to exempt a child from various vaccines. As of July 12, TDH had received 13,435 requests for affidavits covering 4,921 children.
The Autism Debate
Exacerbating already low immunization rates is the growing antivaccine movement spawned over concerns that some vaccines are linked to autism.
Research published in the British medical journal Lancet in 1998 claimed to have demonstrated a potential link between autism and the MMR vaccine. Those findings caused MMR immunization rates in Britain to plummet and measles rates to climb.
That report, along with concerns about the potential harmful effects of thimerosal, a mercury-containing preservative formerly used in childhood vaccines, caused concern among American parents. Thousands are choosing to skip the MMR vaccine or not to have their children immunized at all. That's despite the U.S. Food and Drug Administration ordering thimerosal removed from childhood vaccines, and numerous studies, including a recent Institute of Medicine (IOM) report, failing to find a link between MMR and/or thimerosal and autism.
In fact, the credibility of the original British research on MMR was questioned when it was learned that the lead investigator, Andrew Wakefield, MD, failed to disclose that his work was supported by funds from a group of parents suing vaccine manufacturers. Even though Dr. Wakefield stands by his conclusions, 10 of 13 physicians involved in the original report have withdrawn their support for its findings. (Dr. Wakefield is moving the headquarters of his autism research and treatment program from London to Austin.)
Fixing Vaccine Finance
Despite concerns about thimerosal and autism, the vast majority of Americans remain confident in the benefits of vaccines, and public health officials are looking to improve overall immunization rates. In August 2003, the IOM called for radical changes in how vaccines are purchased and distributed in the United States.
"Immunizations against common, dangerous diseases convey valuable health and social benefits, but the higher prices of newly developed vaccines and the outmoded system by which they are financed create significant financial burdens on health plans, consumers, health providers, and vaccine makers," said Frank Sloan, PhD, chair of the IOM's Committee on Evaluation of Vaccine Purchase Financing in the United States. Dr. Sloan, a Duke University economics professor, said the committee is offering "a plan that both ensures access to vaccines for those in need and creates incentives for private investment in the vaccine industry that would sustain the development and manufacture of these products in the future."
The three-part IOM plan would require all private and public insurance plans, including Medicare, Medicaid, and the state Children's Health Insurance Program, to cover vaccinations. It also urges the federal government to provide a subsidy to reimburse health plans and health care professionals for the costs created by the mandate. Lastly, the federal government would offer vouchers giving anyone not covered by insurance access to immunizations, and reimbursing clinicians who administer vaccines.
IOM also proposed a pricing system that would base the amount the government pays for vaccines on an independent, evidence-based assessment of a vaccine's "societal value."
Dr. Eisenberg attended a meeting on the IOM proposals in June. He says physicians, hospital representatives, and vaccine makers expressed several concerns about the proposal. These included whether it would provide an adequate return for vaccine companies and adequate payment for physicians giving vaccines to at least cover the cost of giving shots or provide a small profit.
Tackling Texas' Problems
Meanwhile, TDH is trying to improve Texas' national immunization ranking. Working with TMA, TDH is set to launch a continuous, statewide education program for parents and physicians. The goal is to increase use of reminder and recall programs in physicians' practices to boost immunization rates (see " Physicians to Launch Immunization Drive ").
The agency also launched a 2003-04 immunization media campaign that focuses on the value of fully vaccinating children and the risks and contraindications of immunizations. That campaign includes targeted media to reach the inner-city communities in Houston and Dallas, where immunizations rates are among the lowest in the state.
TDH also is working to implement legislative mandates to increase participation in ImmTrac. Adriana Rhames, ImmTrac program specialist, says TDH officials are enthusiastic about the impact those changes will have on the effectiveness of the registry.
"The best part is going to be that the responsibility of collecting written parental consent is no longer going to fall on the providers or the insurance companies," she said. "This will now be a TDH responsibility."
That means physicians and health plans can report all vaccinations to ImmTrac and let TDH verify consent and discard records for which consent has not been obtained.
On the Horizon
While public health officials grapple with how to increase the use of existing vaccines, dozens, if not hundreds, of new vaccines are in the pipeline. Dr. Eisenberg says an improved meningococcal vaccine and a rotavirus vaccine are among the closest to coming on the market, possibly within the next year.
Other vaccines under development target sexually transmitted diseases, as well as certain types of staph infections, E. coli bacteria, and emerging diseases such as SARS and West Nile virus.
The University of Texas Medical Branch at Galveston's Seal Center for Vaccine Development has more than 100 research programs on vaccines for diseases ranging from malaria to genital herpes to enteric bacteria such as H. pylori .
Dr. Eisenberg predicts between 15 and 20 new vaccines could be in use within the next 10 years. "The potential is huge," he said.
Ken Ortolon can be reached by telephone at (880) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
"Vaccine-Preventable Diseases and Year of Vaccine Development of Licensure, United States, 1798-1998"
"20th Century Annual Morbidity and Current Morbidity of Vaccine-Preventable Diseases, United States"
"20th Century Annual Morbidity and Current Morbidity of Vaccine-Preventable Diseases, Texas"
Few would argue that vaccines are among medicine's greatest achievements. Yet nearly a third of Texas children under age 3 lack at least one dose of recommended vaccine against diphtheria, tetanus, pertussis, polio, or measles.
That could change starting in October when the Texas Medical Association and the TMA Alliance launch Be Wise-Immunize.
Be Wise-Immunize is a three-year program, funded by the TMA Foundation, that will focus on improving Texas' childhood immunization rates and boosting immunizations among adolescents and adults. The project also will improve TMA's and the TMA Alliance's relationships with the Texas Department of Health (TDH) and other private and public immunization-related groups and build on efforts already under way.
"Nothing could be more tragic than a child dying from a disease that could be prevented," said TMA President Bohn D. Allen, MD. As TMA's president-elect, Dr. Allen chaired TMA's Joint Committee on Health Improvement Initiatives, which developed the Be Wise-Immunize campaign. "The recent scare of measles coming out of Mexico is a perfect example of why we have to be vigilant on this."
The program is designed to promote immunizations to physicians, patients, and the public as important, effective, and safe. It also encourages education, communication, and action on the part of physicians and the public.
"Our whole premise is that we've got to educate not just the public but physicians, as well, on the importance of immunizations," said Andrew Eisenberg, MD, chair of the TMA Council on Public Health. Dr. Eisenberg says physicians need to do a better job of taking every opportunity to catch children up on their vaccines, as well as offering influenza vaccine to all patients during flu season.
"From the standpoint of someone who's interested in public health, the better immunized our society is, the better health we are going to have," Dr. Eisenberg said. "We're not on the brink of an epidemic yet, but I would like to see us be vaccinated before the epidemic comes, and it will. Influenza, in particular, is going to be a major problem again."
Be Wise-Immunize kicks off during TMA's Summit 2004 on Friday, Oct. 1, at the Renaissance Austin Hotel. The first year of the campaign will focus on immunizing children. The second will spotlight adolescent immunization, and the third year will stress adult immunization.
The project has six primary objectives, including mobilizing physicians, alliance members, and medical students to provide immunizations and education directly to children, adolescents, and adults through outreach efforts. Other objectives include:
TMA already has donated $15,000 to TDH to increase the use of reminder and recall programs in physicians' practices to help parents remember to keep their children on schedule with their vaccines.