A Healthier Future for West Virginia - Healthy People 2010

14 - Immunization and Infectious Diseases

Objectives | References

Background

Despite the progress that has been made in the fight against vaccine-preventable diseases and tuberculosis, new infectious diseases continue to arise. During the early 1990s, several major outbreaks called attention to the crumbling public health infrastructure in surveillance and disease control. In 1993, hamburgers contaminated with Escherichia coli O157:H7 caused a multi-state outbreak of hemorrhagic colitis (bloody diarrhea) and hemolytic uremic syndrome, resulting in the deaths of at least four children. That same year, contamination of a municipal water supply with Cryptosporidium caused an outbreak of diarrheal illness in an estimated 403,000 persons, with the hospitalization of 4,400. In the early part of the decade, other recognized threats included multi-drug-resistant pneumoccocal disease, Influenza A/Beijing/32/92, and Hantavirus.

In response to these threats, the Centers for Disease Control and Prevention (CDC) launched an initiative to address emerging infectious diseases. Increased federal funding to states and localities followed in the form of the Epidemiology and Laboratory Capacity (ELC) grants. West Virginia has received funding through ELC grants since 1995. Since that time, West Virginia has begun surveillance for invasive pneumoccocal disease and drug-resistant pneumoccocal disease, Cryptosporidium, Escherichia coli O157:H7, hantavirus, invasive Group A Streptococcal disease, cyclosporiasis, and listeriosis. Through trainings for local and regional personnel, and grants to support regional epidemiologists, our public health infrastructure has improved.

Since the first CDC initiative, several new emerging infectious diseases have been recognized. It is known that 1.8% of people in the U.S. are infected with hepatitis C (2.7 million people). During the summer of 2000, West Nile virus spread across New York State and has been identified between Baltimore and Washington. This disease is very close to our borders. Staphylococcus aureus with intermediate resistance to Vancomycin has been isolated several times in the U.S., and methicillin-resistant Staphylococcus aureus is now recognized as a cause of infection in previously healthy teens and young children. Cyclospora caused outbreaks of gastrointestinal disease two summers in a row. Bat strain rabies has been recognized as the cause of 20 deaths in the U.S. during the 1990s, compared to two deaths the decade before. One of these occurred in West Virginia in 1994. Avian influenza in Hong Kong highlighted the potential for pandemic influenza. Disease outbreaks from bioterrorist acts have been recognized as a real possibility. Finally, infectious agents are increasingly recognized as the cause of chronic conditions, including peptic ulcer disease (Helicobacter pylori), cirrhosis and hepatocellular carcinoma (hepatitis B and C), Kaposi's sarcoma (human herpes virus 8), and cervical cancer (human papilloma virus).

The challenge of public health readiness remains. Only by successfully addressing threats we recognize and understand can we build our capacity to address the next emerging infectious disease. In efforts to help reach WV Healthy People 2010 goals, the importance of increasing resources for infants to adults cannot be overstated. Financing of immunization services will need the continued collaboration between the public and private sectors.

A report issued by the National Vaccine Advisory Committee (NVAC) identified cost as a barrier to children receiving timely immunization services. The Childhood Immunization Initiative (CII) was established as one of the recommendations from the NVAC report with a specific goal of removing barriers from immunizations. The implementation of the federal/state Vaccine for Children (VFC) Program in October 1994 has assisted the improvement of preschool immunization coverage in West Virginia's population by removing cost as a barrier.

During the past 20+ years, West Virginia, like the nation, has been successful in immunizing over 95% of its schoolchildren. However, the immunization coverage of preschool children remains a challenge at both the state and national levels. The measles outbreak between 1989-91, which resulted in over 130 deaths (predominately in young children), was a wake-up call that something was wrong with the country's vaccine delivery system to preschoolers. By the time they reach 15-18 months of age, children should have received 80% of the required vaccine doses. Preschool children, however, currently have much lower vaccination rates. National surveys indicate approximately 20% of the nation's and 18% of West Virginia's preschool children have not been fully immunized.

West Virginia's preschool immunization rates continue to improve, however, when compared to national measures. According to the National Immunization Survey (NIS), a composite measure of vaccination coverage most recently conducted between January and December of 1999, West Virginia's immunization coverage levels for children two years of age for the vaccine combination of 4:3:1 and 4:3:1:3 were 82.1% and 81%, respectively, compared to the United States averages of 79.9% and 78.4%. Even though the state has made great progress in improving coverage in school-age and preschool children, the challenges of improving adult immunization coverage remain. For example, Behavioral Risk Factor Surveillance System (BRFSS) data from 1998 reveal that only 41.3% of persons 65 and older received pneumoccocal immunizations and 58.2% received an influenza vaccine. Influenza/pneumoccocal and its related complications is the sixth leading cause of death in West Virginia.

Activities to help improve immunization in adults range from designating a person on staff to specifically address this high-risk population to assisting in a statewide coalition. West Virginia's Immunization Network (WIN) was established in 1997 with an overall mission to help improve immunization rates across the life span. Within WIN, there is an established adult immunization work group. Additionally, members of WIN represent a cross section of local, state, and community organizations with a similar mission.

The Immunization Program continues to collaborate with West Virginia's Medical Institute (WVMI), which also serves as a Peer Review Organization (PRO) for Medicare. Both entities work closely with WIN and others in the overall effort to improve immunization coverage in the state's aging population. WVMI, in collaboration with the West Virginia Hospital Association and West Virginia Health Care Authority, developed an "In-Patient Immunization Took Kit," a collection of resources to help ensure that patients are vaccinated for influenza and pneumonia while they are hospitalized.

The Immunization Program and other stakeholders must continue to collaborate with non-traditional partners (pharmacists, school-based clinics, etc.) and others in the overall efforts to increase immunization coverage in the adult population in order to reduce the morbidity and mortality in this population. In addition, the program will plan and implement various activities focusing on senior citizens groups. From the private sector, the main target group will be reached through hospital wellness groups for adults 65+ and through nutrition programs.

A recent report issued by WVMI indicated that in 1992-93 the average length of stay for flu and pneumonia among all Medicare populations in West Virginia was 9.2 days, with an average cost per stay of $9,685 and a total cost of slightly more than $75 million. When flu-related illnesses, such as congestive heart failure and other respiratory conditions, were considered, the total cost was more than $215 million.

Even as progress and activities related to adults and preschool immunizations increase, there remains the challenge of improving immunization levels in adolescents.

Both traditional and non-traditional modes of delivering information to the public are used to help promote immunization: written news releases, public service announcements, printed literature, etc. All educational efforts focus on raising awareness among West Virginians that vaccine-preventable diseases still exist and are a threat to those who are not properly immunized. The Newborn Packet Program has been expanded to at least 90% of birthing centers and hospitals in West Virginia. The re-designed packet, entitled "Special Delivery for Baby," has received positive feedback from birthing facilities and county health departments.

Programmatic policies and procedural changes and the Advisory Committee on Immunization Practices (ACIP) recommendations are distributed and teleconference training opportunities are linked to health care professionals to help ensure a well-trained work force. The West Virginia Immunization Program facilitates provider and community links (e.g., local WIC agencies, religious, professional, and service organizations) as a means of persuading providers to check immunization records and bring children up to date with their vaccinations.

Immunizations against vaccine-preventable diseases is only one tool that is used to help eliminate and reduce infectious disease in West Virginia. An example of a critical infectious disease for which there is no vaccine is tuberculosis. The World Health Organization (WHO) released a report demonstrating that tuberculosis, the world's number one infectious cause of death, is threatening to become untreatable. Multi-drug resistant TB has emerged worldwide and is overwhelming national health systems in the former Soviet Union, India, Dominican Republic, Ivory Coast, and other countries.

The United States is by no means immune. With over 40% of U.S. patients diagnosed with TB from the foreign-born population, it is clear that the health of this country is linked with the rest of the world. With more than two million international travelers every single day, our borders cannot detain this airborne disease.

Many of the individuals treated at West Virginia's tuberculosis clinics are foreign born; however, the state has a larger number of patients who are homeless (12% of reported cases in 1999) and people who abuse alcohol (27% in 1999). By age, the largest number of cases of TB are among patients 65 and over (51% in 1999). Lack of jobs, decent housing, good transportation, and adequate medical care combined with increasing age and substance abuse are all stressful life events, and persons under stress are more prone to illness, including tuberculosis.

Achievements have been made by West Virginia regarding tuberculosis. The goal of a TB incidence rate of 3.5 cases per 100,000 population by 2000 was reached in this state in 1996, and our present incidence rate is 2.3 (1999). In order to maintain the downward trend and meet the 2010 objective of 1 case per 100,000, a more aggressive approach in contact investigations and treatment of latent tuberculosis infection needs to occur. The goal of at least 90% of patients completing curative therapy within 12 months has not been met. In 1998, 67% of patients completed therapy within 12 months; 19% took medication longer than 12 months, with a total of 87% completing therapy. A very low percentage of patients are given directly observed therapy. Measures need to be taken to increase this percentage as the lifestyles of patients change and behavioral barriers to treatment increase.

The Objectives

FLAGSHIP OBJECTIVE
OBJECTIVE 14.1. Reduce hepatitis B rates in persons less than 25 years of age to zero cases per 100,000 (except perinatal infections). (Baseline: .33 per 100,000 in 1999)

Data Source: West Virginia Bureau for Public Health (WVBPH), Office of Epidemiology and Health Promotion (OEHP), Division of Surveillance and Disease Control (DSDC), West Virginia 1998 National Electronic Telecommunication System for Surveillance

OBJECTIVE 14.2. Reduce estimated hepatitis B cases per 100,000 among adults older than 25 years of age.
14.2a. Reduce cases among adults aged 25-39 to 0.9 per 100,000. (Baseline: 3.5 in 1999)
14.2b. Reduce cases among adults aged 40 and older to 0.3 per 100,000. (Baseline: 1.3 in 1999)

Data Source: WVBPH, OEHP, DSDC, West Virginia 1998 National Electronic Telecommunication System for Surveillance

OBJECTIVE 14.3. Reduce newly acquired hepatitis C cases to an incidence of no more than 1 per 100,000 people. (Baseline: 1.6 in 1998)

Data Source: WVBPH, OEHP, DSDC, West Virginia 1998 National Electronic Telecommunication System for Surveillance

Hepatitis C is the most common cause of chronic hepatitis in the U.S. The virus is spread predominantly through injection drug use. Transfusions and transplantation as vehicles of transmission are losing prominence as donors are screened with better tests. Persons on dialysis are also at risk, though transmission in that setting can be controlled with good infection control practices in dialysis units. Finally, education of at-risk individuals is increasing as the threat of hepatitis C is better understood. All these factors should reduce the incidence of new cases.

OBJECTIVE 14.4. (Developmental) Increase the number of persons with chronic hepatitis C virus (HCV) infection who are identified by state and local health departments. (Baseline data available in 2003)

Data Source: WVBPH, OEHP, DSDC, Infectious Disease Epidemiology Program

Persons with hepatitis C have improved outcomes if they cease or drastically reduce alcohol consumption. They should also receive hepatitis A vaccine to reduce the chances of liver failure if this form of hepatitis is contracted. Finally, improved treatments offer new hope to persons infected with hepatitis C. For all these reasons, persons at risk of hepatitis C should be identified and referred to medical care.

OBJECTIVE 14.5. Reduce tuberculosis to an incidence of no more that 1.0 per 100,000. (Baseline: 2.3 in 1999)

Data Source: WVBPH, OEHP, DSDC, Tuberculosis Program

OBJECTIVE 14.6. Reach the goal of at least 95% for the proportion of all tuberculosis patients who complete curative therapy within 12 months. (Baseline: 79% in 1997)

Data Source: Tuberculosis in the United States, CDC

It is imperative that a person with infectious tuberculosis disease complete an appropriate course of therapy. Inadequate treatment can lead to relapse, continued transmission, and the development of drug- resistant TB. Directly observed therapy helps to ensure that patients adhere to therapy.

OBJECTIVE 14.8. (Developmental) Reduce the incidence of invasive pneumococcal infections and invasive penicillin-resistant pneumococcal infections in persons aged less than five and 65+.
14.8a. Reduce the incidence of invasive pneumococcal infections in persons less than five years to 46 per 100,000. (Baseline data available in 2003)
14.8b. Reduce the incidence of invasive pneumococcal infections in persons aged 65+ to 50 per 100,000. (Baseline data available in 2003)
14.8c. Reduce the incidence of invasive penicillin-resistant pneumococcal infections in persons less than five years to 9.4 per 100,000. (Baseline data available in 2003)
14.8d. Reduce the incidence of invasive penicillin-resistant pneumococcal infections in persons aged 65+ to 6.8 per 100,000. (Baseline data available in 2003)

Data Source: WVBPH, OEHP, DSDC, Infectious Disease Epidemiology Program

OBJECTIVE 14.9. (Developmental) Decrease the incidence of invasive early-onset Group B Streptococcal disease to 0.5 cases per 1,000 births. (Baseline data available in 2005)

Data Source: WVBPH, OEHP, DSDC, Infectious Disease Epidemiology Program

Invasive Group B Streptococcal disease is a potentially serious disease of newborn infants in the first seven days of life. The disease is transmitted from mother to infant during birth and may cause severe illness or death in the newborn. Fortunately, women can be screened for colonization with Group B Streptococcus, either by using a risk factor profile or by vaginal cultures. Mothers at risk for transmitting Group B Streptococcus can be treated prophylactically with penicillin to prevent transmission to the infant.

OBJECTIVE 14.10. (Developmental)
Reduce hospitalizations caused by peptic ulcer disease to 57 per 100,000 population. (Baseline data available by 2005)

Data Source: WV Health Care Authority

OBJECTIVE 14.11. Maintain or increase immunization coverage of at least 90% among children 19-35 months of age. (1998 baselines below)
14.11a. At least 3 doses of diphtheria-tetanus-pertussis (DtaP) vaccine. (Baseline: 90%)
14.11b. At least 3 doses of Hib vaccine. (Baseline: 97%)
14.11c. At least 1 dose of measles-mumps-rubella vaccine. (Baseline: 93%)
14.11d. At least 3 doses of hepatitis B vaccine. ( Baseline: 90%)
14.11e. At least 1 dose of varicella vaccine. (Baseline: 43%)
14.11f. At least 3 doses of polio vaccine. (Baseline: 92%)
14.11g. A combination of at least four doses of DTaP, three doses of polio, one dose of measles-mumps-rubella (MMR), and three doses of Hib - series abbreviated as 4:3:1:3. (Baseline: 82.4%)

Data Sources: WVBPH, OEHP, DSDC, Immunization Program; CDC, National Immunization Survey

OBJECTIVE 14.12. Maintain immunization coverage at 95% for children in licensed day care facilities and children in kindergarten through the first grade. (1998-99 baselines for recommended immunizations above)

Data Source: WVBPH, OEHP, DSDC, Immunization Program

OBJECTIVE 14.13. Increase the proportion of adults 65 years of age or older and high-risk adults 18-64 years of age who are vaccinated against influenza and pneumococcal disease.
14.13a. Increase the proportion of noninstitutionalized adults 65 years+ who are vaccinated for:
14.13a.1. Influenza to 90%. (Baseline: 58% in 1997)
14.13a.2. Pneumococcal disease to 90%. (Baseline: 41% in 1997)
14.13b. Increase the proportion of noninstitutionalized high-risk adults aged 18-64 who are vaccinated for:
14.13b.1. Influenza to 60%. (Baseline: 30% in 1995)
14.13b.2. Pneumococcal disease to 60%. (Baseline: 15% in 1995)
14.13c. Increase the proportion of institutionalized adults (persons in long-term care or nursing homes) who have been vaccinated for:
14.13c.1. Influenza to 90%. (Baseline: 62% in 1995)
14.13c.2. Pneumococcal disease to 90%. (Baseline: 23% in 1995)

Data Sources: National Health Interview Survey, CDC; National Centers for Health Statistics, National Nursing Home Survey; WVBPH, OEHP, Behavior Risk Factor Surveillance System (BRFSS)

OBJECTIVE 14.14. Increase to at least 85% the proportion of contacts, including other high-risk persons with tuberculosis infection, who complete courses of preventive therapy. (Baseline: 71% in 1998)

Data Source: WVBPH, OEHP, DSDC, Tuberculosis Program.

OBJECTIVE 14.15. Increase the proportion of immunization providers who have systematically measured the immunization coverage levels in their practice populations within the last two years to 90%.
14.15a. Public health providers (Baseline: 40% in 1999 [provisional data])
14.15b. Private providers (Baseline: 5% in 1999 [provisional data])

Data Source: WVBPH, OEHP, DSDC, Immunization Program

OBJECTIVE 14.16. Increase the proportion of children enrolled in a fully functional state/community population-based immunization registry to at least 95%. (Baselines: Annual birth cohort - 99%; children birth through five - 28% in 2000)

Data Source: WVBPH, OEHP, DSDC, Immunization Program

Immunization registries, confidential, computerized information systems that contain information on the shots children receive, are proven tools for sustaining high immunization coverage. This system will allow West Virginia to monitor the immunization status of children, utilize data for outreach and follow-up activities, and assess coverage rates for providers and jurisdictions. The West Virginia Statewide Immunization Information System (WVSIIS) will compile information on every private immunization provider throughout the state.

The WVSIIS will help eliminate missed opportunities for immunization since all health care providers in West Virginia will have access to immunization histories of all West Virginia children less than six years of age. The WVSIIS will serve the basic functions of querying the system and entering new data, tracking and notification of children needing immunizations, and using data for planning and evaluation purposes. Local health departments (LHDs) and providers will be able to perform outreach, follow-up activities for children requiring immunization services, and identification of populations at risk for delayed immunizations. Approximately 23,000 births occur in West Virginia each year; of these, 38% are immunized in LHDs and 62% in the private sector.

OBJECTIVE 14.17. (Developmental) Decrease the number of inappropriate rabies postexposure prophylaxis, as defined by the current Advisory Committee on Immunization Practices guidelines. (Baseline data available in 2005)

Data Source: WVBPH, OEHP, DSDC, Infectious Disease Epidemiology Program

Meeting the Objectives

Health Promotion Channels for Achieving Objectives:

• Worksites
• Schools
• Public Health Programs
• Networks
• Health Care Systems
• Higher Education

The following list includes some of the organizations that will be leading the initiatives to reach the 2010 objectives:

West Virginia Immunization Program
West Virginia Infectious Disease Epidemiology Program
West Virginia Immunization Network (WIN)
Office of Epidemiology and Health Promotion, WVBPH

The West Virginia Bureau for Public Health's Office of Epidemiology and Health Promotion is the coordinating agency for WIN. The coalition, in collaboration with others, will address the problem of immunization and infectious diseases in the state by using the six health promotion channels listed above.

Work Group Members

Samuel W. Crosby, Jr., Work Group Leader, Director, West Virginia Immunization
Program, WVBPH
Loretta E. Haddy, MA, MS, Director, Division of Surveillance and Disease
Control, WVBPH
Charles P. Schrade, MD, MPH, WVMI
Rhonda Kennedy, RN, Director of Nursing, Kanawha-Charleston Health
Department
Francis Gillenwater, RN, Director of Nursing, Putnam County Health Department
Carolyn Winkler, RN, Director, West Virginia Tuberculosis Program, West Virginia Immunization Program, WVBPH
Derald Rollyson, Assessment Coordinator, West Virginia Immunization Program, WVBPH
Danae Bixler, MD, Director, Infectious Disease Epidemiology Program, WVBPH
Thomasini Trosi, Parent Representative, Governor's Cabinet on Children, Youth and Families
Michelle Foster, Community Representative, Grace Bible Church
Nicholas Haddad, student intern, DSDC, WVBPH
Linda Elders, Community Health Educator, WV Immunization Program, DSDC, WVBPH

References/Resources

Federal Interagency Forum on Children and Family Statistics. America's Children: Key National Indicators of Well-Being 2000. Washington, DC: U.S. Government Printing Office, 2000.

Berkelman RL, Pinner RW, Hughes JM. "Addressing emerging microbial threats in the United States." JAMA 275 (1996): 315-7.

CDC. Addressing Emerging Infectious Disease Threats: A Prevention Strategy for the United States. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, 1994.

CDC. Preventing Emerging Infectious Disease Threats: A Strategy for the Twenty-first Century. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, 1998.

CDC. West Virginia 2000 - State Health Profile. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, 2000.

Division of Health Promotion and Disease Prevention, Institute of Medicine. Calling the Shots, Immunization Finance Policies and Practices. Washington, DC: National Academy Press, 2000.

Flora JA and Lefebure RC. "Social marketing and public health intervention." Health Education Quarterly 15, no. 3 (Fall 1988): 299-315.

Hughes JM et al. "Addressing the challenges of emerging infectious diseases: implementation of the strategy of the Centers for Disease Control and Prevention." In: Emerging Infections. Washington, DC: ASM Press, 1998.

Institute of Medicine. Emerging Infections: Microbial Threats to Health in the United States. Washington, DC: National Academy Press, 1994.

Legislative Briefing. Childhood Immunization Registry. Monday, May 1, 2000.

"Medicare Institute aims at getting serious to get flu shots." Medicare News (April 2000).

Orenstein WA and Zorab R, eds. Vaccines, 3rd ed. Philadelphia, PA: W.B. Saunders, 1999.

West Virginia Bureau for Public Health. West Virginia Healthy People 2000 Mid-course Review. Charleston, WV: West Virginia Department of Health and Human Resources, April 1997.

West Virginia Health Care Association and West Virginia Hospital Association. West Virginia's Year 2000-Inpatient Immunization Tool Kit. Charleston, WV: WVMI, 2000.

WVMI. "Health Care Quality Improvement Program." Quality Time 2 (2000).

For More Information

West Virginia Immunization Program
Office of Epidemiology and Health Promotion
Room 125
350 Capitol Street
Charleston, WV 25301-3715
Phone: (304) 558-2188; Fax: (304) 558-1941

This page was last updated June 21, 2001.
For additional information about HP2010, contact Chuck Thayer at (304) 558-0644 or Chuck.E.Thayer@wv.gov