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
"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
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
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
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
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
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
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
"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
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
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
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
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
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
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 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
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,
bacteria, and emerging diseases such as SARS and West Nile
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
Dr. Eisenberg predicts between 15 and 20 new vaccines could be
in use within the next 10 years. "The potential is huge," he
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
"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"
Physicians to Launch Immunization Drive
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
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
"Nothing could be more tragic than a child dying from a disease
that could be prevented," said TMA President Bohn D. Allen, MD. As
president-elect, Dr. Allen chaired
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
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
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:
- Training and educating physicians to become effective
spokespersons on immunizations.
- Providing physicians with tools to remind themselves, their
staffs, their patients, and their patients' parents about the
need for immunizations, and how to take advantage of all patient
- Increasing physicians' understanding of the myths and facts
related to immunization safety.
- Enhancing physicians' participation in the ImmTrac vaccine
registry and Texas Vaccines for Children program.
- Increasing public understanding of myths and facts related to
immunization safety, using partner organizations whenever
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
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