1. IMMUNIZATIONS IN 2014 HEAD TO TOE CONFERENCEMAY 2014 Lance Chilton, M.D. Professor, Pediatrics University of New Mexico

2. THE REASON WE IMMUNIZE Achievements in Public Health, 1900-1999 Impact of Vaccines Universally Recommended for Children -- United States, 1990-1998 At the beginning of the 20th century, infectious diseases were widely prevalent in the United States and exacted an enormous toll on the population. For example, in 1900, 21,064 smallpox cases were reported, and 894 patients died (1). In 1920, 469,924 measles cases were reported, and 7575 patients died; 147,991 diphtheria cases were reported, and 13,170 patients died. In 1922, 107,473 pertussis cases were reported, and 5099 patients died (2,3). Dramatic declines in morbidity have been reported for the nine vaccine-preventable diseases for which vaccination was universally recommended for use in children before 1990 (excluding hepatitis B, rotavirus, and varicella). Morbidity associated with smallpox and polio caused by wild-type viruses has declined 100% and nearly 100% for each of the other seven diseases. MMWR, April 2, 1999

3. Q: WHAT IS STILL THE MOST COMMON VACCINE- PREVENTABLE DISEASE?

4. A: INFLUENZA AKA: “JUST THE FLU” Average Annual United States Incidence of Influenza Outcomes Under 5 Years5-17 YearsTotal Population “Just sick”2,030,0003,296,00012,414,000 Outpatient visit1,741,0001,535,0007,282,000 Hospitalized54,3432,805195,776 Deaths1424321,282 Molinari et al. Vaccine 25 (2007) 5086–5096

5. INFLUENZA DEATHS IN CHILDREN

6. X X X X X X X X X XX X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X XX X X X X X X X X X NEW MEXICO’S SCHOOL KIDS’ INFLUENZA IMMUNIZATION PROJECT

7. KUDOS TO SKIIP AND TO ALL OF YOU!

8. EARLY ALBUQUERQUE DATA: FLU  SCHOOL ABSENCES Gurule, Escareno, Dharas, Pentler, Skipper and Chilton, unpublished

9. DOESN’T HE EVER STOP TALKING ABOUT INFLUENZA? HE DOES.

10. WHERE DO IMMUNIZATION RECS COME FROM? American Academy of Pediatrics Committee on Infectious Diseases (Red Book Committee) : meets twice a year, produces Red Book every 3 years ACIP – Next Meeting: June 25-26, 2014, Atlanta Informational items Votes

11. RED BOOK COMMITTEE

12. Screen for Powerpoints Head Table Members MM L Liaisons L Audience Podium ACIP Jonathan Tempte Larry Pickering

13. www.cdc.gov/vaccines ACIP Products

14. A BIT ABOUT VACCINE SAFETY

15. ARE VACCINES SAFE? AND WHAT’S VAERS ANYWAY? Vaccine Adverse Effects Reporting System

16. VSD

17. THE VACCINE SAFETY DATALINK This is the most robust vaccine safety system; there are others (example: military).

18. THE ROTASHIELD® STORY (BORN 1998, DIED 1999) Rotavirus kills some 450,000 children per year around the world; 20-60 in the United States Early 1990s, clinical trials showed 80-100% effectiveness against severe rotavirus diarrhea and excellent safety profile 1998: RotaShield licensed Late 1998: reports to VAERS of many cases of intussusception after RotaShield receipt VAERS Signal reported to VSD, which affirmed the hypothesis that RotaShield associated with intussusception 1999: Rotashield removed from market. Early 2000s, clinical trials on far more children showed no association with intussusception for two new vaccines, Rotarix® and Rotateq® 2006: Rotarix and Rotateq approved by FDA and recommended by ACIP SUCCESS OR FAILURE OF THE VACCINE SAFETY SYSTEM?

19. HOW SHOULD WE COMMUNICATE HOW SAFE VACCINES ARE?

20. PENN AND TELLER’S APPROACH TO VACCINE SAFETY DISCUSSION Viewer Discretion Advised

21. PAUL OFFITT’S APPROACH

22. DR. BOB SEARS’ APPROACH

23. DR. SEARS’ VACCINE SCHEDULE

24. TOO MANY ANTIGENS? 2012: 2 month shots: Antigens: Rotavirus5 Pediarix  Diphtheria1  Tetanus1  Pertussis 3  Polio 3  Hepatitis B1 H. Influenzae B1 Pneumococcal 13 Total 28 Streptococcal Infection = 25-50 antigens Upper respiratory infection = 4-10 antigens In the old days: Smallpox vaccine = ~200 antigens Whole cell pertussis vaccine = ~3000 antigens

25. DECLINING NUMBER OF ANTIGENS:

26. VACCINES AREN’T FREE But no, folks, you won’t have to pay for vaccines in New Mexico (yet).

27. IN 42 STATES… But only for Uninsured Native Americans/Alaska Natives Medicaid insured Underinsured But only in FQHC or RHC

28. IN 6 STATES (NH, RI, VT, WI, WY AND… For all children and adolescents before their 19 th birthday NEW MEXICO!) Alaska, Hawaii, Maine, Massachusetts, South Dakota, Washington cover most but not all childhood vaccines

29. ARE THESE VACCINES AFFORDABLE? In Arizona, Colorado, Utah, Texas and most other states, the total private sector price of all vaccines for each person (except influenza) through age 18 was $2171 + vaccine administration as of April 2014. In New Mexico, the price to patients is $0 + vaccine administration Vaccines for Children for everyone in New Mexico is under attack!

30. VaccineDosesTotal Pediarix3$211 Rotateq3$226 Hib4$93 Pneumo4$543 MMR2$112 Varivax2$188 Hep A2$61 DTaP2$21 Polio IPV1$27 TOTAL$1482 VaccineDosesTotal Gardasil3$425 Menactra2$226 Tdap1$38 TOTAL$689 WHY IS THIS IMPORTANT? Vaccines for the first five years Vaccines for adolescence Vaccine Total Cost per Child $2171 plus Influenza Vaccine, $8-23/dose April 1, 2014, CDC data

31. IS IT WORTH IT? FIGURES FOR ONE BIRTH COHORT – 2009: 4.26 MILLION BIRTHS DiseaseCases Prevented Deaths Prevented Direct Costs Saved, Million $ Societal Costs Saved (Direct + Indirect), Million $ Diphtheria 275 02827 503 3654 39 296 Tetanus169251245 Pertussis 2 950 836 106244437017 Hib 19 606 74118103756 Polio 67 463 80028987259 Measles 3 835 825 310637628862 Mumps 2 312 275 1214112374 Rubella 1 981 066 15187721 Congenital rubella syndrome 63270133257 HepB 239 993 35142401770 Varicella 3 942 546 733731598 HepA 153 164 3652114 Pneumococcus- related diseases b b 2 323 952 50569652696 Rota 1 582 940 19327595 Total 19 685 49542 03220 26776 360 DEATHSTHAT’S $20 BILLION and $76 BILLION! Cost:benefit ratio Direct costs only: 3.0 Total societal costs: 10.1 Zhou F et al. Economic Evaluation of the Routine Childhood Immunization Program in the US, 2009. Pediatrics, 2014. 133:577.

32. RESULTS… VFC VACCINE for everyone else $90,000

33. THAT’S THE BUSINESS SIDE; HOW ABOUT THE PERSONAL CONTEXT?

34. THIS IS WHY WE DO IT… DiseaseAnnual Cases – Pre-Vaccine Era Annual Cases Since Vaccine Percent Reduction Diphtheria175,8850100% Tetanus13142898% Measles503,2824399.9% Mumps152,20980099.5% Rubella47,7451299.9% Congenital Rubella Syndrome 8230100% Polio16,3160100% Haemophilus influenzae b 20,0005499.7%

36. MY PATIENT, POST HIB MENINGITIS Age 34

37. HOW’RE WE DOING ON INDIVIDUAL ADOLESCENT VACCINES? ? CDC 2012 NIS data in MMWR, Aug. 30, 2013 UK 90 80 70 60 50 40 30 20 10 HOW DO THEY DO THAT? Vaccines for Children for everyone in New Mexico is under attack!

38. CERVICAL CANCER IN NEW MEXICO Incidence Race/Ethnicity Age-adjusted rate Average number of new cases Percent of all new cases Rank among all new cancer cases † NM, Non-Hispanic White6.5321.3%13 NM, Hispanic9.0352.8%10 NM, American Indian6.562.7%13 NM, Black5.212.0%11 NM, All Races Combined*761.9%* US, All Races Combined § 7.411,0701.6%1.6%13 Mortality Race/Ethnicity Age-adjusted rate Average number of cancer deaths Percent of all cancer deaths Rank among all cancer deaths † NM, Non-Hispanic White1.7101.1%15 NM, Hispanic3.1122.6%12 NM, American Indian3.533.5%10 NM, Black---- NM, All Races Combined * 261.7%* US, All Races Combined § 2.4 3,8703,8701.4%14 New Mexico Tumor Registry, 2006-2010 data

40. Prevalence of individual human papillomavirus (HPV) types among females aged 14–19 years, 2003–2006 and 2007–2010. Markowitz L E et al. J Infect Dis. 2013;208:385-393 Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2013.

41. SPECIAL COMMUNIQUÉ FROM THE FRONT HPV VACCINATION DOES NOT CAUSE TEENAGERS TO HAVE SEX Mayhew A et al. Sexual Behaviors after HPV Vaccination. Pediatrics, 2014. 133:404.

42. Yes That’s where the kids are! We could teach about the diseases prevented No School nurses already have too many tasks Some vaccines are too controversial SHOULD WE GIVE MORE VACCINES IN NEW MEXICO SCHOOLS?

43. THANK YOU FOR ALL YOU DO! "Schools have a wealth of potential for ensuring the future well-being of young people. You can't educate a child who isn't healthy, and you can't keep a child healthy who isn't educated." -- M. Jocelyn Elders, MD