Immunization Principles and Vaccine Use: (Table 122-1) (Table 122-2)

Immunization Principles
and Vaccine Use

Anne Schuchat
Lisa A. Jackson
Few medical interventions of the past century can rival the effect
that immunization has had on longevity, economic savings, and
quality of life. Seventeen diseases are now preventable through
vaccines routinely administered to children and adults in the
United States ( Table 122-1 ) , and most vaccine-preventable diseases
of childhood are at historically low levels ( Table 122-2 ) . Health care
providers deliver the vast majority of vaccines in the United States
in the course of providing routine health services and therefore play
an integral role in the nations public health system.
_ VACCINE IMPACT
Direct and indirect effects
Immunizations against specific infectious diseases protect individuals
against infection and thereby prevent symptomatic illnesses. Specific
vaccines may blunt the severity of clinical illness (e.g., rotavirus vaccines
and severe gastroenteritis) or reduce complications (e.g., zoster
vaccines and postherpetic neuralgia). Some immunizations also
reduce transmission of infectious disease agents from immunized
people to others, thereby reducing the impact of infection spread.
This indirect impact is known as herd immunity . The level of immunization
in a population that is required to achieve indirect protection
of unimmunized people varies substantially with the specific vaccine.
Since childhood vaccines have become widely available in the
United States, major declines in rates of vaccine-preventable
diseases among both children and adults have become evident
( Table 122-2 ). For example, vaccination of children <5 years of
age against seven types of Streptococcus pneumoniae led to a >90%
overall reduction in invasive disease caused by those types. A series
of vaccines targeting 10 vaccine-preventable childhood diseases in a
single birth cohort leads to prevention of 33,000 premature deaths
and 14 million illnesses and saves $42 billion (U.S.): $9 billion in
direct medical savings and $33 billion in indirect societal savings.
Control, elimination, and eradication of vaccine-preventable diseases
Immunization programs are associated with the goals of controlling,
eliminating, or eradicating a disease. Control of a vaccine- preventable
disease reduces illness outcomes and often limits the disruptive
impacts associated with outbreaks of disease in communities, schools,
and institutions. Control programs can also reduce absences from
work for ill persons and for parents caring for sick children, decrease
absences from school, and limit health care utilization associated with
treatment visits.
Elimination of a disease is a more demanding goal than control,
usually requiring the reduction to zero of cases in a defined geographic
area but sometimes defined as reduction in the indigenous
sustained transmission of an infection in a geographic area. As of
2010, the United States had eliminated indigenous transmission
of measles, rubella, poliomyelitis, and diphtheria. Importation of
pathogens from other parts of the world continues to be important,

and public health efforts are intended to react promptly to such
cases and to limit forward spread of the infectious agent.
Eradication of a disease is achieved when its elimination can
be sustained without ongoing interventions. The only vaccinepreventable disease that has been globally eradicated
thus far is smallpox. Although smallpox vaccine is no longer given
routinely, the disease has not naturally reemerged because all chains
of human transmission were interrupted through earlier vaccination
efforts and humans were the only natural reservoir of the virus.
Currently, a major health initiative is targeting the global eradication
of polio. Sustained transmission of polio has been eliminated
from most nations but has never been interrupted in four countries:
Afghanistan, India, Nigeria, and Pakistan. Detection of a case of
disease that has been targeted for eradication or elimination is considered
a sentinel event that could permit the infectious agent to
become reestablished in the community or region. Hence, such
episodes must be promptly reported to public health authorities.
Outbreak detection and control
Clusters of cases of a vaccine-preventable disease detected in
an institution, a medical practice, or a community may signal
important changes in the pathogen, vaccine, or environment.
Several factors can give rise to increases in vaccine-preventable
disease, including (1) low rates of immunization that result in an
accumulation of susceptible people (e.g., measles resurgence among
vaccination abstainers); (2) changes in the infectious agent that permit
it to escape vaccine-induced protection (e.g., nonvaccine-type
T

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Immunization Principles

and Vaccine Use

pathogens from other parts of the world continues to be important,

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