The 2006 Recommended Childhood and Adolescent Immunization Schedule, published in this issue of American Family Physician,1 is a joint product of the Centers for Disease Control and Prevention’s (CDC’s) National Immunization Program, the American Academy of Family Physicians (AAFP), and the American Academy of Pediatrics. Its unveiling, during the 50th anniversary of the licensure of the Salk poliovirus vaccine, allows reflection on two basic premises of childhood and adolescent immunization. First, children are vaccinated to reduce serious illness and death. Second, any vaccine that comes into widespread use in the United States tends to diffuse into the developing world, usually at greatly reduced cost.
I have had the pleasure to serve the AAFP on vaccine policy issues and am one of two AAFP liaisons to the Advisory Committee on Immunization Practices (ACIP). My involvement with immunization issues has provided three profound experiences that I would like to share.
In March 2000, I represented the AAFP at the CDC’s Measles Elimination Meeting. Like many family physicians entering practice in the early 1990s, I knew very little about measles and even less about disease elimination. I walked away with a newfound respect for measles and, after reviewing the extensive evidence, voted that measles had been eliminated from the United States. Accordingly, the United States has attained a level of vaccination at which sustained transmission of measles is no longer possible.2 That said, measles remains a leading cause of childhood death worldwide, accounting for an estimated 530,000 preventable deaths in 2003.3 The cost to immunize a child against measles in a developing country amounts to less than $1.
In October 2004, 36 years after licensure of the rubella vaccine, rubella received elimination status in the United States.4 Congenital rubella syndrome, with its attendant blindness, deafness, and heart defects, has been relegated to the past.
As a new liaison to ACIP in June 2004, I was invited to join the Meningococcal Working Group. With input from the AAFP Commission on Clinical Policy and Research and the AAFP Immunization Cooperative Advisory Group, I helped shape the recommendations for the recently licensed tetravalent meningococcal polysaccharide-protein conjugate vaccine (MCV4; Menactra). Though relatively rare, meningococcal disease may result in significant sequelae for its victims and their families, communities, and health care professionals.5 In making the final recommendations, the working group and ACIP demonstrated interest in and response to the sensibilities and sensitivities of family physicians. Three target groups—children 11 and 12 years of age, adolescents at high school entry, and college freshmen planning to live in dormitories—were determined based on sound epidemiology, vaccine properties, and an interest in creating a “preadolescent platform” for appropriate vaccine delivery and discussion of other important preventive health issues. However, most cases of meningococcal disease occur in the developing world; U.S. cases account for only 0.1 percent of the estimated 171,000 meningococcal-related deaths each year.6
The past year brought a notable reemergence of pertussis. Waning immunity from the birth-to-five-years diphtheria-tetanus-pertussis/diphtheria, tetanus toxoids, and acellular pertussis vaccine series likely contributed to epidemic spread, especially in adolescents. The pre-adolescent visit provides an excellent opportunity to boost pertussis immunity. Two recently licensed tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis adsorbed (Tdap) vaccines, Adacel and Boostrix, contain antigens for tetanus, diphtheria, and pertussis and are approved for use in adolescents. Tdap vaccine can be administered safely with MCV4.
Fifty years ago, family physicians could only dream of the elimination of polio, measles, and rubella. Through the combined and cooperative efforts of researchers, manufacturers, public health practitioners, legislators, parents, pediatricians, and family physicians, these diseases are mostly memories. We are witnessing dramatic declines in varicella and hepatitis A infections and in invasive disease from Haemophilus influenzae type B and pneumococcus. Continued cooperative efforts to ensure high levels of childhood vaccine coverage are essential to protect our children and children throughout the world. To this end, the AAFP has approved the 2006 Recommended Childhood and Adolescent Immunization Schedule.