Financing immunization of adults in the United States.

Immunization is one of the most effective and cost-effective prevention measures available. As a result of universal vaccination of children, polio has been eliminated in the United States and much of the world, measles and rubella are no longer endemic diseases in the United States, and most of the other vaccine-preventable diseases of childhood are at or near record lows. A recent review of clinical preventive services by Partnership for Prevention gave childhood immunization a perfect score of 10, based on clinically preventable burden and cost-effectiveness.

Perspectives on the state of combination vaccines: summary of the rapporteur for the International Symposium on Combination Vaccines.

Recent advances in immunology, biotechnology, and other sciences now give the prospect of a wide variety of new vaccines that can bring further improvements in health but that pose some theoretical issues relating to safety and efficacy, as well as practical issues relating to logistics, number of injections, and other factors. Combination vaccines are essential if society is to take full advantage of new vaccines that can further reduce the burden of infectious diseases in this country and around the world. The major issues relating to combination vaccines are much the same today as those discussed at a 1993 meeting. However, considerable progress has been made in developing solutions to the problems, and prospects are good that many of these issues will be resolved in the next 2-3 years.

Motor-vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts, and reducing alcohol-impaired driving.

The Task Force on Community Preventive Services has conducted systematic reviews of interventions designed to increase use of child safety seats, increase use of safety belts, and reduce alcohol-impaired driving. The Task Force strongly recommends the following interventions: laws requiring use of child safety seats, distribution and education programs for child safety seats, laws requiring use of safety belts, both primary and enhanced enforcement of safety belt use laws, laws that lower the legal blood alcohol concentration (BAC) limit for adult drivers to 0.08%, laws that maintain the minimum legal drinking age at 21 years, and use of sobriety checkpoints. The Task Force recommends communitywide information and enforcement campaigns for use of child safety seats, incentive and education programs for use of child safety seats, and a lower legal BAC for young drivers (in the United States, those under the minimum legal drinking age). This report provides additional information regarding these recommendations, briefly describes how the reviews were conducted, and provides information to help apply the interventions locally.

How should physicians and nurses deal with people who do not want immunizations?

People who do not want immunizations represent a small fraction of the total population. However, they may have significant epidemiologic impact. Reasons for lack of support for immunization include ignorance, fear, contraindication, general opposition based on religion or philosophy, or "informed" opposition. The category of "informed" opposition includes those who have decided, based on reliable information, that the risks of immunization outweigh the benefits in their particular case. It also includes "misinformed" opposition arising from acceptance of unproven allegations about vaccine safety or efficacy. These views may be fostered by media accounts of adverse events alleged to be caused by vaccines. Carefully developed and forthright responses to these issues are needed to assure that people make truly informed immunization decisions.

Costs of immunization registries: experiences from the All Kids Count II Projects.

BACKGROUND: Immunization registries are tools to improve and sustain immunization coverage rates for our nation's preschool children. Developing a means of supporting registries over the long term requires information on costs to operate registries. METHODS: To determine the annual cost per child to operate immunization registries for the 16 All Kids Count (AKC) II projects, some of the most developed registry projects in the United States, we projected a national figure for operating registries and compared the figure with a variety of potential cost offsets. RESULTS: When the registries are fully operational, the average cost per child for the 16 AKC II projects will be $3.91 (range, $1.60 to $6.23; interquartile range, $2.91 to $4.81) per year. CONCLUSIONS: Based on the AKC study, maintaining a nationwide network of registries for children aged 0 to 5 will require an estimated $78.2 million. Cost offsets include not having to manually retrieve records for school entry, child care, change in provider, and Health Plan Employer Data Information Set reports; not having to carry out the National Immunization Survey; and prevention of overimmunization. We estimate these offsets at $113.8 million annually.

Developing the Guide to Community Preventive Services--overview and rationale. The Task Force on Community Preventive Services.

When the GUIDE TO COMMUNITY PREVENTIVE SERVICES: Systematic Reviews and Evidence-Based Recommendations (the Guide) is published in 2001, it will represent a significant national effort in encouraging evidence-based public health practice in defined populations (e.g., communities or members of specific managed care plans). The Guide will make recommendations regarding public health interventions to reduce illness, disability, premature death, and environmental hazards that impair community health and quality of life. The Guide is being developed under the guidance of the Task Force on Community Preventive Services (the Task Force)-a 15-member, nonfederal, independent panel of experts. Subject matter experts, methodologists, and scientific staff are supporting the Task Force in using explicit rules to conduct systematic literature reviews of evidence of effectiveness, economic efficiency, and feasibility on which to base recommendations for community action. Contributors to the Guide are building on the experience of others to confront methodologic challenges unique to the assessment of complex multicomponent intervention studies with nonexperimental or nonrandomized designs and diverse measures of outcome and effectiveness. Persons who plan, fund, and implement population-based services and policies to improve health at the state and local levels are invited to scrutinize the work in progress and to communicate with contributors. When the Guide is complete, readers are encouraged to consider critically the value and relevance of its contents, the implementation of interventions the Task Force recommends, the abandonment of interventions the Task Force does not recommend, and the need for rigorous evaluation of the benefits and harms of promising interventions of unknown effectiveness.

Developing an evidence-based Guide to Community Preventive Services--methods. The Task Force on Community Preventive Services.

Systematic reviews and evidence-based recommendations are increasingly important for decision making in health and medicine. Over the past 20 years, information on the science of synthesizing research results has exploded. However, some approaches to systematic reviews of the effectiveness of clinical preventive services and medical care may be less appropriate for evaluating population-based interventions. Furthermore, methods for linking evidence to recommendations are less well developed than methods for synthesizing evidence. The Guide to Community Preventive Services: Systematic Reviews and Evidence-Based Recommendations (the Guide) will evaluate and make recommendations on population-based and public health interventions. This paper provides an overview of the Guide's process to systematically review evidence and translate that evidence into recommendations. The Guide reviews evidence on effectiveness, the applicability of effectiveness data, (i.e., the extent to which available effectiveness data is thought to apply to additional populations and settings), the intervention's other effects (i.e., important side effects), economic impact, and barriers to implementation of interventions. The steps for obtaining and evaluating evidence into recommendations involve: (1) forming multidisciplinary chapter development teams, (2) developing a conceptual approach to organizing, grouping, selecting and evaluating the interventions in each chapter; (3) selecting interventions to be evaluated; (4) searching for and retrieving evidence; (5) assessing the quality of and summarizing the body of evidence of effectiveness; (6) translating the body of evidence of effectiveness into recommendations; (7) considering information on evidence other than effectiveness; and (8) identifying and summarizing research gaps. Systematic reviews of and evidence-based recommendations for population-health interventions are challenging and methods will continue to evolve. However, using an evidence-based approach to identify and recommend effective interventions directed at specific public health goals may reduce errors in how information is collected and interpreted, identify important gaps in current knowledge thus guiding further research, and enhance the Guide users' ability to assess whether recommendations are valid and prudent from their own perspectives. Over time, all of these advantages could help to increase agreement regarding appropriate community health strategies and help to increase their implementation.

Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. The Task Force on Community Preventive Services.

This paper presents the results of systematic reviews of the effectiveness, applicability, other effects, economic impact, and barriers to use of selected population-based interventions intended to improve vaccination coverage. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis for recommendations by the Task Force on Community Preventive Services (the Task Force) regarding the use of these selected interventions. The Task Force recommendations are presented on pp. 92-96 of this issue.

Vaccine adverse events in the new millennium: is the sky really falling?

PIP: Brian Ward's article regarding immunization safety has caused experts with long immunization experience to dismiss the paper out of hand as alarmist. Some of the reasons for this include the following: 1) lack of context or balance; 2) presentation of an indiscriminate and unlabelled mixture of conjecture, speculation, hypothesis and fact; 3) the plea for essentially unlimited resources to study vaccine safety issues; and 4) the inclusion of societal or indirect costs in economic analyses. However, the author states that the significant negative features of Ward's paper should not overshadow key issues in vaccine safety and vaccine adverse events mentioned in the paper. These include the following: 1) novel approaches to vaccine composition or presentation and new combinations of vaccines raise additional possibilities for adverse events; 2) state-of-the-art technology must continue to be applied to studies of vaccine safety as the technologies develop; 3) more resources need to be devoted to studies of vaccine safety; 4) industrialized countries will have to bear the primary burden of these studies as they are beyond the resources of most developing countries; 5) communication to the public about risks and benefits of vaccines is both essential and complex; and 6) open discussion in the scientific community about vaccine adverse events is essential but needs to be conducted in a way that neither unduly alarms people nor appears to minimize the issues.^ieng

The immunization system in the United States - the role of school immunization laws.

School immunization laws have had a remarkable impact on vaccine-preventable diseases in the United States, particularly in school-aged populations. Enforcement of laws through the exclusion of unvaccinated children from school is a critical factor in assuring success. All laws have exemptions for medical contraindications, 47 states have exemptions for persons with strong religious beliefs against vaccination and 15 states have exemptions for persons philosophically opposed to vaccination. Fewer than 1% of students have any type of exemption in most states. School laws harness the resources of other programs such as education to the immunization effort. They establish a safety net to assure high levels of coverage each and every year. But they cannot replace efforts to assure age appropriate immunization in the first two years of life.

Economic aspects of vaccines and immunizations.

Several techniques are used to estimate whether investing in vaccines and immunization is worthwhile, including cost analysis, cost-benefit analysis, cost-effectiveness analysis, and cost-utility analysis. At least 162 published economic evaluations of vaccines have been carried out from 1969 to 1998. They consistently show that immunization is an excellent investment--highly cost-effective and usually cost-saving--for vaccines that are currently recommended for universal use. Although prices of newer vaccines are higher than prices of traditional vaccines, they are still highly cost-effective. The World Health Organization, UNICEF, and vaccine manufacturers have developed approaches to make newer vaccines available to developing countries at reduced prices. Sustainability of immunization programs (the ability of a country to continue its immunization program in the absence of external support) is an increasingly important goal. However, external assistance will be essential in the short term to ensure that all the world's people benefit fully from the new vaccines.

Rational use of rubella vaccine for prevention of congenital rubella syndrome in the Americas.

Rubella is a viral disease with minor morbidity and few complication unless it is contracted by a pregnant woman. Rubella infection during the first trimester of pregnancy often leads to fetal death or severe congenital defects (congenital rubella syndrome, CRS). Rubella remains endemic in many countries of Latin America and the Caribbean. It has been estimated that 20,000 or more infants are perhaps born with CRS each year in Latin American and Caribbean countries. While the inclusion of rubella vaccination into routine childhood immunization will decrease rubella virus circulation among young children, it will not have immediate impact on the transmission of rubella among adults or the occurrence of CRS. A one-time mass campaign targeting both males and females 5 to 39 years of age with measles-mumps-rubella or measles-rubella vaccine followed by the use of measles-mumps-rubella vaccine in routine early childhood vaccination will prevent and control both rubella and CRS promptly. In April 1988, the Ministers of Health of the English-speaking Caribbean targeted rubella for elimination by the end of the year 2000 using the vaccination strategy outlined above. The rubella elimination experience of these countries will provide useful information for the eventual elimination of rubella virus from the Americas.

Evaluating interventions for prevention and control of infectious diseases, Part 2.

This article, the second of a two-part series, describes approaches to evaluate interventions for prevention and control of infectious diseases. Evaluation should take place at all stages in the development and application of such interventions, whether preventive or therapeutic. At least four different types of evaluation can be carried out: developmental evaluation, relevance evaluation, process (administrative) evaluation, and impact evaluation. For therapeutic interventions, cure is the best indicator of effectiveness. For preventive interventions, reduction in the occurrence of the condition is the best measure of effectiveness. However, process and administrative evaluation and economic evaluation also play important roles.

Global progress in infectious disease control.

There is both good news and bad news concerning infectious disease control globally. The good news is that smallpox has been eradicated, eradication of poliomyelitis and guinea worm disease is on track, and many infectious diseases are under effective control in much of the world. The advances are primarily the result of improved sanitation, effective use of vaccines, and introduction and use of specific therapies (whose impact has primarily been on mortality, rather than incidence). The bad news is that infectious diseases are still the leading cause of death world-wide, new diseases are emerging, old diseases are re-emerging, there are ominous interactions between diseases, and antibiotic resistance is emerging as a major problem. There are many promising developments for the future, including new and improved vaccines, new specific therapies, and new strategies to deal with infectious disease. However, unless eradicated, infectious diseases remain a threat and require continuous efforts to be kept under control. Given the ability of infectious agents to evolve, it is certain that the future will also hold new problems and new diseases.

Evaluating interventions for prevention and control of infectious diseases.

This article describes approaches to evaluate interventions for prevention and control of infectious diseases. Evaluation should take place at all stages in the development and application of such interventions, whether preventive or therapeutic. At least four different types of evaluation can be carried out: developmental evaluation, relevance evaluation, process (administrative) evaluation, and impact evaluation. For therapeutic interventions, cure is the best indicator of effectiveness. For preventive interventions, reduction in the occurrence of the condition is the best measure of effectiveness. However, process and administrative evaluation and economic evaluation also play important roles.