# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 14 {#section-1 .Chapter-#}

# Immunization and Infectious Diseases

Lead Agency: Centers for Disease Control and Prevention

### Contents {#contents .Heading-Special}

[Goal Page 14-3](#goal)

[Overview Page 14-3](#overview)

[Issues Page 14-3](#issues)

[Trends Page 14-4](#trends)

[Disparities Page 14-6](#disparities)

[Opportunities Page 14-7](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
14-8](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
14-9](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
14-11](#healthy-people-2010-objectives)

[Diseases Preventable Through Universal Vaccination Page
14-11](#diseases-preventable-through-universal-vaccination)

[Diseases Preventable Through Targeted Vaccination Page
14-18](#diseases-preventable-through-targeted-vaccination)

[Infectious Diseases and Emerging Antimicrobial Resistance Page
14-22](#infectious-diseases-and-emerging-antimicrobial-resistance)

[Vaccination Coverage and Strategies Page
14-35](#vaccination-coverage-and-strategies)

[Vaccine Safety Page 14-49](#vaccine-safety)

[Related Objectives From Other Focus Areas Page
14-51](#related-objectives-from-other-focus-areas)

[Terminology Page 14-52](#terminology)

[References Page 14-54](#references)

## Goal

Prevent disease, disability, and death from infectious\
diseases, including vaccine-preventable diseases.

## Overview

Infectious diseases remain major causes of illness, disability, and
death. Moreover, new infectious agents and diseases are being detected,
and some diseases considered under control have reemerged in recent
years. In addition, antimicrobial resistance is evolving rapidly in a
variety of hospital- and community-acquired infections. These trends
suggest that many challenges still exist in the prevention and control
of infectious diseases.

### Issues

Between 1980 and 1992, the number of deaths from infectious diseases
rose 58 percent in the United States.[^1] Even when human
immunodeficiency virus (HIV)-associated diagnoses are removed, deaths
from infectious diseases still increased 22 percent during this period.
(See Focus Area 13. HIV.) Considered as a group, three infectious
diseases---pneumonia, influenza, and HIV infection---constituted the
fifth leading cause of death in the United States in 1997.Error:
Reference source not found

The direct and indirect costs of infectious diseases are significant.
Every hospital-acquired infection adds an average of \$2,100 to a
hospital bill. Bloodstream infections result in an average of \$3,517 in
additional hospital charges per infected patient because the patient
stay averages an additional 7 days. A typical case of Lyme disease
diagnosed in the early stages incurs about \$174 in direct medical
treatment costs. Delayed diagnosis and treatment, however, can result in
complications that cost from \$2,228 to \$6,724 per patient in direct
medical costs in the first year alone.[^2]

Infectious diseases also must be considered in a global context.
Increases in international travel, importation of foods, inappropriate
use of antibiotics on humans and animals, and environmental changes
multiply the potential for worldwide epidemics of all types of
infectious diseases. International cooperation and collaboration on
disease surveillance, response, research, and training are essential to
prevent or control these epidemics. Actions taken to improve health in
one country affect the health of people worldwide.

**Vaccines.** Vaccines are biological substances that interact with the
person's immune system to produce an immune response identical to that
produced by the natural infection.

Vaccines can prevent the debilitating and, in some cases, fatal effects
of infectious diseases. Vaccines help to eliminate the illness and
disability of polio,[^3] measles, and rubella.[^4] However, the
organisms that cause these diseases have not disappeared. Rather, they
have receded and will reemerge if the vaccination coverage drops. The
serious health burden of vaccine-preventable diseases (VPDs) is evident
from the measles resurgence of 1989 to 1991, resulting in more than
55,000 cases, 11,000 hospitalizations, 120 deaths, and \$100 million in
direct medical care costs.[^5]**^,^** [^6]**^,^** [^7]**^,^** [^8]

Vaccines protect more than the vaccinated individual. They also protect
society. When vaccination levels in a community are high, the few who
cannot be vaccinated---such as young children and persons with
contraindications to vaccination---often are indirectly protected
because of group immunity (in other words, they live among vaccinated
persons who may offer protection from exposure to disease).

Vaccines provide significant cost benefits. Three childhood
vaccines---diphtheria, tetanus toxoids, and acellular pertussis vaccine
(DTaP); measles, mumps, and rubella vaccine (MMR); and *Haemophilus
influenzae* type b (Hib) vaccine---result in substantial direct medical
savings for each dollar spent to vaccinate children against these
diseases. Varicella vaccine saves roughly 90 cents in direct medical
costs for every dollar invested. Consideration of indirect
savings---prevention of work loss by parents to care for ill children
and prevention of death and therefore lost earnings from
disability---shows that vaccines routinely recommended for children are
highly cost saving. Savings range from \$24 for every dollar spent on
DTaP to \$2 for the more recently approved Hib vaccine.[^9]

### Trends

Significant progress has been made in reducing indigenous (not imported)
cases of VPDs. The occurrence of many VPDs is at or near record-low
levels. Most diseases have been reduced by more than 95 percent from
peak prevaccine levels.[^10]

In 1998, overall vaccination coverage for children aged 19 to 35 months
was at record-high levels.[^11] Antigen-specific rates have shown
striking progress since 1992.[^12] For example, coverage for three or
more doses of polio vaccine increased from 72 percent to 91 percent, and
coverage for three or more doses of Hib vaccine increased from 28
percent to 93 percent. Significant achievements were made among racial
and ethnic groups in that most of the 1996 goals for the Childhood
Immunization Initiative were met for individual vaccines.[^13] Since
1989, vaccination requirements have been expanded for schools and day
care settings.Error: Reference source not found As of the 1998--99
school year, all States required vaccination against diphtheria,
measles, and polio. Similarly, all States and the District of Columbia
now require vaccination for children in day care.[^14]

In 1996, a vaccine against hepatitis A virus (HAV) was licensed that has
the potential to reduce the health burden of this disease. The vaccine
is now recommended primarily for high-risk groups. To decrease HAV
transmission, universal vaccination was recommended in 1999 for children
who lived in States where the rate of new cases was greater than two
times the national average.[^15]

Financing for childhood vaccinations has improved significantly as a
result of two initiatives---Vaccines for Children and the State
Children's Health Insurance Program (SCHIP)---that cover children on
Medicaid, uninsured children, and American Indian and Alaska Native
children. Underinsured children who receive vaccinations at federally
qualified health centers also are covered. Because they promote free
vaccines for children, these programs eliminate vaccine cost as a
barrier to childhood vaccination. Also, the Public Health Service Act,
Section 317 immunization grant program and State funds provide free
vaccines for children not covered by other
programs.![](media/image2.wmf){width="4.501388888888889in"
height="4.314583333333333in"}

Vaccination rates among persons aged 65 years and older continued to
increase over the decade. Influenza vaccine coverage rates were up from
33 percent in 1989 to 64 percent in 1998, and pneumococcal vaccine
coverage rates were up from 15 percent to 46 percent. Despite these
increases, coverage rates for certain racial and ethnic groups remain
substantially below the general population.[^16]

Invasive diseases invade the bloodstream and cause distant infection.
The most common types of invasive disease caused by Hib are meningitis,
epiglottitis, pneumonia, certain types of arthritis, and cellulitis.
Conjugate vaccines---licensed in 1990 for use beginning at age 2
months---are highly effective in protecting against Hib meningitis and
other invasive diseases caused by Hib. These vaccines also interrupt
spread of the disease-causing organism by affecting the organism's
nasopharyngeal colonization. New cases of Hib meningitis declined by 96
percent from 1987 to 1995.[^17] During that period, bacterial meningitis
caused by one of the five leading agents (*Haemophilus influenzae*,
*Streptococcus pneumoniae*, *Neisseria meningitidis*, group B
*Streptococcus* \[GBS\], and *Listeria monocytogenes*) fell by 55
percent. Bacterial meningitis was traditionally a disease of childhood,
infecting children with a median age of 15 months in 1986.[^18]
Following the dramatic reduction in Hib meningitis, which primarily
occurs among children under age 2 years, the median age of persons with
the disease shifted to 25 years in 1995.Error: Reference source not
found The success of conjugate vaccines against Hib disease has
stimulated efforts to develop conjugate vaccines for other pathogens,
including *Streptococcus pneumoniae*, *Neisseria meningitidis*, and GBS.
A conjugate vaccine against *S. pneumoniae* has been licensed, and
vaccines against the other two agents are being tested in clinical
trials. The success of bacterial meningitis vaccines suggests comparable
results may be achieved for other causes of meningitis, sepsis, and
pneumonia as their conjugate vaccines become used more routinely in
target populations.

### Disparities

The updated *Preventing Emerging Infectious Diseases: A Strategy for the
21st Century* focuses on certain emerging infectious disease issues and
on particular groups of people at risk.[^19] Historically, childhood
vaccination rates have been lower in certain racial and ethnic
populations, compared to the white population. Vaccination rates for
preschool children in racial and ethnic groups with lower vaccination
rates, however, have been increasing at a more rapid rate, significantly
narrowing the gap.

Efforts need to be intensified, particularly to increase vaccination
coverage for children living in poverty. Substantial numbers of
undervaccinated children remain in some areas, particularly the large
urban areas with traditionally underserved populations, creating great
concern because of the potential for outbreaks of disease.

In addition to very young children, many adults are at increased risk
for VPDs. Vaccination against pneumococcal infections and influenza
among persons aged 65 years and older has increased slightly for African
Americans and Hispanics. The coverage in these groups, however, remains
substantially below the general population. For example, influenza
vaccination rates for whites were 66 percent in 1997, while for African
Americans and Hispanics, rates were only 45 percent and 53 percent,
respectively. In September 1997, the U.S. Department of Health and Human
Services approved a plan to improve adult vaccination rates and reduce
disparities among racial and ethnic groups.[^20] The elimination of
disparities, however, may require further interventions in particular
geographic, cultural, and racial and ethnic populations.

### Opportunities

A coordinated strategy is necessary to understand, detect, control, and
prevent infectious diseases. Such a strategy will protect the gains
achieved in life expectancy in the 20th century from control and
prevention of infectious diseases and ensure further improvements in the
21st century.

Priority issues include antimicrobial resistance, foodborne and
waterborne diseases, vector-borne and zoonotic diseases, diseases
transmitted through transfusion of blood or blood products, and vaccine
development and use. Some of these diseases and pathogens were unknown
20 years ago. Others are reemergent problems once thought under control.
At-risk populations include persons with impaired host defenses;
pregnant women and newborns; travelers, immigrants, and refugees; older
adults; and other persons identified by the Advisory Committee on
Immunization Practices (ACIP).

The major strategies to protect people from VPDs are the following:[^21]

-   Improving the quality and quantity of vaccination delivery services.

-   Minimizing financial burdens for needy persons.

-   Increasing community participation, education, and partnership.

-   Improving monitoring of disease and vaccination coverage.

-   Developing new or improved vaccines and improving vaccine use.

These strategies include a broad range of interventions for children,
such as entry requirements for school and promoting the Vaccines for
Children and SCHIP initiatives, in which eligible children are
vaccinated in their medical home. Assessment of vaccination coverage of
persons served at individual clinics and provider offices with feedback
of the results to the individual providers to guide them in improving
performance also is important. The exchange of information on coverage
assessment among colleagues stimulates a friendly competition to achieve
better vaccination levels.[^22] Populations at risk of undervaccination
can be reached through linkages with other programs, including Women,
Infants, and Children (WIC) services.[^23] State and local registries
that enroll children and record their vaccinations are valuable tools
for helping parents and providers to identify immunization needs of
individual children, assessing coverage in individual practices, and
generating communitywide estimates.[^24]

In the United States, most VPDs occur among adults. Pneumococcal disease
and influenza account for more than 30,000 deaths annually, most of
which occur in elderly persons. Studies have consistently shown that
focusing efforts to improve coverage on health care providers, as well
as health care systems, is the most effective means of raising vaccine
coverage in adults. For example, all health care providers should assess
routinely the vaccination status of their patients. Likewise, health
plans should develop mechanisms for assessing the vaccination status of
their participants. Also, nursing home facilities and hospitals should
ensure that policies exist to promote vaccination.

Because no vaccine is completely safe, vaccine safety research and
monitoring are necessary to identify and minimize vaccine-related
injuries. As programs continue to reduce the new cases of VPDs, concerns
about vaccine adverse events have emerged, posing a threat to public
acceptance of vaccines. Knowing the safety profile of vaccines is
essential to assess accurately the risks and benefits, to formulate
appropriate vaccine recommendations, and to address public concerns.

## Interim Progress Toward Year 2000 Objectives

Significant progress has been made in reaching the Healthy People 2000
objectives. Reductions in indigenous cases of VPDs have been dramatic.
For example, measles was reduced from a 1988 baseline of 3,396
indigenous cases to a total of only 74 in 1998. Substantial progress
also has been made in reducing hepatitis B virus (HBV) transmission. The
vaccine against hepatitis A provides the opportunity to reduce the
burden of this disease. Achieving the year 2000 objective to reduce new
cases of bacterial meningitis was entirely due to the introduction of
Hib conjugate vaccines for infants.[^25] In 1998, individual coverage
levels for children aged 19 to 35 months were at record high levels. For
example, individual coverage levels for three or more doses of polio,
three or more doses of diphtheria/tetanus/acellular pertussis, one or
more doses of measles/mumps/rubella, and three or more doses of Hib
vaccines were each at or above 91 percent. Progress also has been made
in expanding immunization requirements for schools and day care
settings. Data for viral hepatitis indicate that targets for hepatitis B
and C were met in the early 1990s.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Immunization and Infectious Diseases {#immunization-and-infectious-diseases-1 .Heading-Special-Sub}

**Goal:** Prevent disease, disability, and death from infectious
diseases,\
including vaccine-preventable diseases.

  --------------- -------------------------------------------------------------
  **Number**      **Objective Short Title**

  **Diseases      
  Preventable     
  Through         
  Universal       
  Vaccination**   

  14-1            Vaccine-preventable diseases

  14-2            Hepatitis B in infants and young children

  14-3            Hepatitis B in adults and high-risk groups

  14-4            Bacterial meningitis in young children

  14-5            Invasive pneumococcal infections

  **Diseases      
  Preventable     
  Through         
  Targeted        
  Vaccination**   

  14-6            Hepatitis A

  14-7            Meningococcal disease

  14-8            Lyme disease

  **Infectious    
  Diseases and    
  Emerging        
  Antimicrobial   
  Resistance**    

  14-9            Hepatitis C

  14-10           Identification of persons with chronic hepatitis C

  14-11           Tuberculosis

  14-12           Curative therapy for tuberculosis

  14-13           Treatment for high-risk persons with latent tuberculosis
                  infection

  14-14           Timely laboratory confirmation of tuberculosis cases

  14-15           Prevention services for international travelers

  14-16           Invasive early onset group B streptococcal disease

  14-17           Peptic ulcer hospitalizations

  14-18           Antibiotics prescribed for ear infections

  14-19           Antibiotics prescribed for common cold

  14-20           Hospital-acquired infections

  14-21           Antimicrobial use in intensive care units

  **Vaccination   
  Coverage and    
  Strategies**    

  14-22           Universally recommended vaccination of children aged 19 to 35
                  months

  14-23           Vaccination coverage for children in day care, kindergarten,
                  and first grade

  14-24           Fully immunized young children and adolescents

  14-25           Providers who measure childhood vaccination coverage levels

  14-26           Children participating in population-based immunization
                  registries

  14-27           Vaccination coverage among adolescents

  14-28           Hepatitis B vaccination among high-risk groups

  14-29           Influenza and pneumococcal vaccination of high-risk adults

  **Vaccine       
  Safety**        

  14-30           Adverse events from vaccinations

  14-31           Active surveillance for vaccine safety
  --------------- -------------------------------------------------------------

## Healthy People 2010 Objectives

### Diseases Preventable Through Universal Vaccination

14-1. Reduce or eliminate indigenous cases of vaccine-preventable
diseases.

Target and baseline:

+----------+------------------------+---------------+-----------------+
| O        | Reduction in           | 1998\         | 2010\           |
| bjective | Vaccine-Preventable    | Baseline      | Target          |
|          | Diseases               |               |                 |
+----------+------------------------+---------------+-----------------+
|          |                        | ######### Nu  |                 |
|          |                        | mber of Cases |                 |
+----------+------------------------+---------------+-----------------+
| **       | Congenital rubella     | 7             | 0               |
| 14-1a.** | syndrome (children     |               |                 |
|          | under age 1 year)      |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Diphtheria (persons    | 1             | 0               |
| 14-1b.** | under age 35 years)    |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | *Haemophilus           | 163           | 0               |
| 14-1c.** | influenzae*\           |               |                 |
|          | type b**\*** (children |               |                 |
|          | under age\             |               |                 |
|          | 5 years)               |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Hepatitis B (persons   | 945^†^        | 9               |
| 14-1d.** | aged\                  |               |                 |
|          | 2 to 18 years)         |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Measles (persons of    | 74            | 0               |
| 14-1e.** | all ages)              |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Mumps (persons of all  | 666           | 0               |
| 14-1f.** | ages)                  |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Pertussis (children    | 3,417         | 2,000           |
| 14-1g.** | under\                 |               |                 |
|          | age 7 years)           |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Polio (wild-type       | 0             | 0               |
| 14-1h.** | virus)\                |               |                 |
|          | (persons of all ages)  |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Rubella (persons of    | 364           | 0               |
| 14-1i.** | all ages)              |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Tetanus (persons       | 14            | 0               |
| 14-1j.** | under\                 |               |                 |
|          | age 35 years)          |               |                 |
+----------+------------------------+---------------+-----------------+
| **       | Varicella (chicken     | 4 million^‡^  | 400,000         |
| 14-1k.** | pox)\                  |               |                 |
|          | (persons under age 18  |               |                 |
|          | years)                 |               |                 |
+----------+------------------------+---------------+-----------------+

\*Includes cases with type b and unknown serotype.

^†^Estimated hepatitis B cases for 1997.[^26]

^‡^Data based on average from 1990--94 for persons of all ages.

**Target setting method:** Total elimination for congenital rubella
syndrome,\
diphtheria, *Haemophilus influenzae* type b, measles, mumps, polio,
rubella, and tetanus; 41 percent improvement for pertussis; 99 percent
improvement for\
hepatitis B; and 99 percent improvement for varicella.

**Data sources:** National Notifiable Disease Surveillance System
(NNDSS), CDC, EPO; National Congenital Rubella Syndrome Registry
(NCRSR), CDC,\
NIP---congenital rubella syndrome; Active Bacterial Core Surveillance
(ABCs), Emerging Infections Programs, CDC, NCID---*Haemophilus
influenzae* type b; National Health Interview Survey (NHIS), CDC,
NCHS---varicella.

Highly effective vaccines are used routinely in childhood for prevention
of measles, mumps, rubella, varicella, diphtheria, tetanus, pertussis,
polio, hepatitis B, and invasive Hib disease.[^27] Vaccinations for
these diseases have reduced reported cases of most VPDs common in
childhood to record-low levels.Error: Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^28] Measles
transmission probably was interrupted multiple times in the United
States since 1993.[^29]**^,^** [^30]**^,^** [^31] With a high level of
coverage of two doses of measles, mumps, and rubella vaccine,
interruption of the spread of both rubella and mumps is
feasible.[^32]**^,^** [^33] Recent outbreaks of rubella and a number of
cases of congenital rubella syndrome, however, highlight the importance
of ensuring rubella immunity, particularly in women of child-bearing age
and foreign-born adults.[^34] Polio has been eliminated in the United
States due to high vaccination coverage. Although polio is expected to
be eradicated globally, surveillance for cases of the disease will
continue. Because of widespread vaccination, reported cases of
diphtheria are near zero.[^35]**^,^** [^36] Tetanus toxoid is highly
effective, but with the absence of group immunity, all persons must be
vaccinated to achieve the goal of zero cases.[^37] Pertussis among
children will be reduced by increasing vaccination coverage, but the
disease will continue to occur because the organism circulates among
older age groups, and the vaccine is not 100 percent
effective.[^38]**^,^** [^39]

Hepatitis B virus (HBV) infection will be reduced greatly as the age
groups covered by universal infant and adolescent vaccination efforts
enter young adulthood, a period when the risk of HBV infection
increases.

Conjugate vaccines for prevention of Hib are highly effective and have
led to near elimination of invasive Hib disease.Error: Reference source
not found**^,^** [^40] Further reductions in new cases are anticipated
as Hib vaccine coverage increases.

The licensure of new vaccines against common diseases that are not
reportable diseases, such as varicella, has created new challenges for
surveillance and evaluation. Without national reporting, documenting the
impact of national and State vaccination programs and measuring progress
for reducing indigenous cases of disease are difficult.[^41] However,
with an increase in vaccination coverage and a decline in the number of
new cases, varicella is expected to become a reportable condition.

14-2. Reduce chronic hepatitis B virus infections in infants and young
children (perinatal infections).

**Target:** 400 infections.

**Baseline:** 1,682 chronic hepatitis B virus infections in children
under age 2 years were reported in 1995.

**Target setting method:** 76 percent improvement.

**Data sources:** Perinatal Hepatitis B Prevention Program, CDC, NCID;
National Vital Statistics System (NVSS), CDC, NCHS; State Perinatal
Hepatitis B\
Prevention Programs; State Vital Statistics Systems.

Each year, 16,000 to 18,000 children in the United States are born to
mothers infected with HBV.[^42] Without prevention programs, about 8,000
of these infants would become infected with HBV. Ninety-five percent of
the infections, however, are preventable through appropriate maternal
screening and infant care.[^43]

Screening pregnant women during an early prenatal visit is essential to
identify those who are infected. Women at high risk should be retested
late in pregnancy. In 1997, 14 States had laws or regulations to ensure
such screening.

To be maximally effective, steps to prevent transmission of HBV to
infants born to mothers who are infected must begin as soon as the child
is born. Such infants should receive a first dose of hepatitis B vaccine
within 12 hours of birth, along with hepatitis B immune globulin (HBIG),
and two more doses of vaccine by age 6 months. Children need to be
tested between the ages of 12 and 15 months to ensure that they are not
infected and have developed immunity to the virus.

14-3. Reduce hepatitis B.

Target and baseline:

+----------+----------------------------+--------------+--------------+
| O        | Reduction in Hepatitis B   | 1997\        | 2010\        |
| bjective |                            | Baseline     | Target       |
+==========+============================+==============+==============+
|          | **Adults**                 | *Rate per    |              |
|          |                            | 100,000      |              |
|          |                            | Population*  |              |
+----------+----------------------------+--------------+--------------+
| **       | 19 to 24 years             | 24.0         | 2.4          |
| 14-3a.** |                            |              |              |
+----------+----------------------------+--------------+--------------+
| **       | 25 to 39 years             | 20.2         | 5.1          |
| 14-3b.** |                            |              |              |
+----------+----------------------------+--------------+--------------+
| **       | 40 years and older         | 15.0         | 3.8          |
| 14-3c.** |                            |              |              |
+----------+----------------------------+--------------+--------------+
|          | **High-risk groups**       | #            |              |
|          |                            | ######## Num |              |
|          |                            | ber of Cases |              |
+----------+----------------------------+--------------+--------------+
| **       | Injection drug users       | 7,232        | 1,808        |
| 14-3d.** |                            |              |              |
+----------+----------------------------+--------------+--------------+
| **       | Heterosexually active      | 15,225       | 1,240        |
| 14-3e.** | persons                    |              |              |
+----------+----------------------------+--------------+--------------+
| **       | Men who have sex with men  | 7,232        | 1,808        |
| 14-3f.** |                            |              |              |
+----------+----------------------------+--------------+--------------+
| **       | Occupationally exposed     | 249          | 62           |
| 14-3g.** | workers                    |              |              |
+----------+----------------------------+--------------+--------------+

**Target setting method:** Better than the best for 14-3a, 14-3b, and
14-3c; 75 percent improvement for 14-3d, 14-3f, and 14-3g; 92 percent
improvement for 14-3e.

**Data sources:** National Notifiable Disease Surveillance System
(NNDSS), CDC, EPO; Sentinel Counties Study of Viral Hepatitis, CDC,
NCID.

+---------------------------------+---------+---+-----------+------------+
| **Select Age Groups, 1997**     | **He    |   |           |            |
|                                 | patitis |   |           |            |
|                                 | B       |   |           |            |
|                                 | Cases** |   |           |            |
+=================================+=========+===+===========+============+
|                                 | **      |   | **14-3b.\ | **14-3c.\  |
|                                 | 14-3a.\ |   | Aged 25   | Aged 40    |
|                                 | Aged 19 |   | to 39     | Years and  |
|                                 | to 24   |   | Years**   | Older**    |
|                                 | Years** |   |           |            |
+---------------------------------+---------+---+-----------+------------+
|                                 | Rate    |   |           |            |
|                                 | per     |   |           |            |
|                                 | 100,000 |   |           |            |
+---------------------------------+---------+---+-----------+------------+
| **TOTAL**                       | 24.0    | 2 |           | 15.0       |
|                                 |         | 0 |           |            |
|                                 |         | . |           |            |
|                                 |         | 2 |           |            |
+---------------------------------+---------+---+-----------+------------+
| ###### Race and ethnicity       |         |   |           |            |
+---------------------------------+---------+---+-----------+------------+
| > American Indian or Alaska     | 16.0    | 2 |           | 10.9       |
| > Native                        |         | 0 |           |            |
|                                 |         | . |           |            |
|                                 |         | 1 |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Asian or Pacific Islander     | 42.2    | 3 |           | 33.2       |
|                                 |         | 0 |           |            |
|                                 |         | . |           |            |
|                                 |         | 4 |           |            |
+---------------------------------+---------+---+-----------+------------+
| Asian                           | DNC     | D |           | DNC        |
|                                 |         | N |           |            |
|                                 |         | C |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Native Hawaiian and other     | DNC     | D |           | DNC        |
| > Pacific Islander              |         | N |           |            |
|                                 |         | C |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Black or African American     | 48.3    | 3 |           | 27.6       |
|                                 |         | 2 |           |            |
|                                 |         | . |           |            |
|                                 |         | 5 |           |            |
+---------------------------------+---------+---+-----------+------------+
| > White                         | 10.4    | 1 |           | 7.4        |
|                                 |         | 0 |           |            |
|                                 |         | . |           |            |
|                                 |         | 2 |           |            |
+---------------------------------+---------+---+-----------+------------+
|                                 |         |   |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Hispanic or Latino            | 16.9    | 1 |           | 18.1       |
|                                 |         | 6 |           |            |
|                                 |         | . |           |            |
|                                 |         | 0 |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Not Hispanic or Latino        | 25.2    | 2 |           | 14.8       |
|                                 |         | 0 |           |            |
|                                 |         | . |           |            |
|                                 |         | 7 |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Black or African American     | 50.6    | 3 |           | 28.4       |
|                                 |         | 4 |           |            |
|                                 |         | . |           |            |
|                                 |         | 1 |           |            |
+---------------------------------+---------+---+-----------+------------+
| > White                         | 10.3    | 1 |           | 7.1        |
|                                 |         | 0 |           |            |
|                                 |         | . |           |            |
|                                 |         | 2 |           |            |
+---------------------------------+---------+---+-----------+------------+
| **Gender**                      |         |   |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Female                        | 24.1    | 1 |           | 9.4        |
|                                 |         | 5 |           |            |
|                                 |         | . |           |            |
|                                 |         | 4 |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Male                          | 22.5    | 2 |           | 20.8       |
|                                 |         | 4 |           |            |
|                                 |         | . |           |            |
|                                 |         | 1 |           |            |
+---------------------------------+---------+---+-----------+------------+
| **Family income level**         |         |   |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Poor                          | DNC     | D |           | DNC        |
|                                 |         | N |           |            |
|                                 |         | C |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Near poor                     | DNC     | D |           | DNC        |
|                                 |         | N |           |            |
|                                 |         | C |           |            |
+---------------------------------+---------+---+-----------+------------+
| > Middle/high income            | DNC     | D |           | DNC        |
|                                 |         | N |           |            |
|                                 |         | C |           |            |
+---------------------------------+---------+---+-----------+------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

To reduce HBV transmission in the United States by 2010, vaccination
programs must be targeted to adolescents and adults in high-risk groups.
The primary means of achieving high levels of vaccination coverage in
groups with behavioral risk factors for HBV infection is to identify
settings where these individuals can be vaccinated. Such sites include
clinics that treat sexually transmitted diseases (STDs), correctional
facilities (juvenile detention facilities, prisons, jails), drug
treatment clinics, and community-based HIV prevention sites. The primary
means of achieving high levels of vaccine coverage among household and
sex contacts of the estimated 1.25 million persons in the United States
with chronic HBV infection are programs that offer followup for all
hepatitis B surface antigen (HBsAg)-positive persons reported to State
and local health departments.

Routine infant vaccination eventually will produce a highly immune
population sufficient to eliminate HBV transmission in the United
States. However, high rates of acute hepatitis B continue to occur, with
an estimated 65,000 cases in 1996. Most cases occur in young adult risk
groups, including persons with a history of multiple sex partners, men
who have sex with men, injection drug users, incarcerated persons, and
household and sex contacts of persons with HBV infection. Investigation
of reported cases of acute hepatitis B indicates that as many as 70
percent of these individuals previously had been seen in settings, such
as drug treatment clinics, correctional facilities, or clinics for the
treatment of STD, where they could have received vaccine.

14-4. Reduce bacterial meningitis in young children.

**Target:** 8.6 new cases per 100,000 children aged 1 through 23 months.

**Baseline:** 13.0 new cases of bacterial meningitis per 100,000
children aged 1 through 23 months were reported in 1998.

**Target setting method:** 34 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** Active Bacterial Core Surveillance (ABCs), CDC, NCID.

Note: The table below may continue to the following page.

+---------------------------------------------+------------------------+
| **Children Aged 1 Through 23 Months, 1998** | **New Cases of\        |
|                                             | Bacterial Meningitis** |
+=============================================+========================+
|                                             | Rate per 100,000       |
+---------------------------------------------+------------------------+
| > **TOTAL**                                 | 13.0                   |
+---------------------------------------------+------------------------+
| **Race and ethnicity**                      |                        |
+---------------------------------------------+------------------------+
| > American Indian or Alaska Native          | DSU                    |
+---------------------------------------------+------------------------+
| > Asian or Pacific Islander                 | DSU                    |
+---------------------------------------------+------------------------+
| > Asian                                     | DNC                    |
+---------------------------------------------+------------------------+
| > Native Hawaiian and other Pacific         | DNC                    |
| > Islander                                  |                        |
+---------------------------------------------+------------------------+
| > Black or African American                 | 25.9                   |
+---------------------------------------------+------------------------+
| > White                                     | 11.0                   |
+---------------------------------------------+------------------------+
|                                             |                        |
+---------------------------------------------+------------------------+
| > Hispanic or Latino                        | DSU                    |
+---------------------------------------------+------------------------+
| > Not Hispanic or Latino                    | DSU                    |
+---------------------------------------------+------------------------+
| > Black or African American                 | DSU                    |
+---------------------------------------------+------------------------+
| > White                                     | DSU                    |
+---------------------------------------------+------------------------+
| ###### Gender                               |                        |
+---------------------------------------------+------------------------+
| > Female                                    | 13.0                   |
+---------------------------------------------+------------------------+
| > Male                                      | 13.1                   |
+---------------------------------------------+------------------------+
| **Family income level**                     |                        |
+---------------------------------------------+------------------------+
| > Poor                                      | DNC                    |
+---------------------------------------------+------------------------+
| > Near poor                                 | DNC                    |
+---------------------------------------------+------------------------+
| > Middle/high income                        | DNC                    |
+---------------------------------------------+------------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Children aged 1 month through 23 months have higher rates of meningitis
than older children. New vaccines for pneumococcal disease, including
pneumococcal meningitis, may help protect young children. Meningococcal
conjugate vaccines are in clinical trials and may become available for
widespread use before 2010, although it is not yet known whether they
will be targeted to young children. Pneumococcal conjugate vaccines,
modeled after the successful construction of Hib conjugate vaccines, are
also in clinical trials. Before 2010, licensure and widespread use of
these new products are expected.

14-5. Reduce invasive pneumococcal infections.

Target and baseline:

+-------------+--------------------------+--------------+-------------+
| Objective   | Reduction in Invasive\   | 1997\        | 2010\       |
|             | Pneumococcal Infections  | Baseline     | Target      |
+-------------+--------------------------+--------------+-------------+
|             |                          | ##           |             |
|             |                          | ####### Rate |             |
|             |                          |  per 100,000 |             |
+-------------+--------------------------+--------------+-------------+
|             | **New invasive           |              |             |
|             | pneumococcal             |              |             |
|             | infections**             |              |             |
+-------------+--------------------------+--------------+-------------+
| **14-5a.**  | Children under age 5     | 76           | 46          |
|             | years                    |              |             |
+-------------+--------------------------+--------------+-------------+
| **14-5b.**  | Adults aged 65 years and | 62           | 42          |
|             | older                    |              |             |
+-------------+--------------------------+--------------+-------------+
|             | **Invasive               |              |             |
|             | penicillin-resistant     |              |             |
|             | pneumococcal             |              |             |
|             | infections**             |              |             |
+-------------+--------------------------+--------------+-------------+
| **14-5c.**  | Children under age 5     | 16           | 6           |
|             | years                    |              |             |
+-------------+--------------------------+--------------+-------------+
| **14-5d.**  | Adults aged 65 years and | 9            | 7           |
|             | older                    |              |             |
+-------------+--------------------------+--------------+-------------+

**Target setting method:** Better than the best.

**Data sources:** Active Bacterial Core Surveillance (ABCs), CDC, NCID;
Arctic\
Investigations Program (for data on pneumococcal disease rates among
Alaska Natives), CDC.

+---------------------------+---------+---------+---------+---------+
| **Select Age Groups,      | **New   |         | **New   |         |
| 1997**                    | Cases   |         | Cases   |         |
|                           | of\     |         | of\     |         |
|                           | In      |         | I       |         |
|                           | vasive\ |         | nvasive |         |
|                           | Pneumo  |         | Penici  |         |
|                           | coccal\ |         | llin-Re |         |
|                           | Infec   |         | sistant |         |
|                           | tions** |         | Pneum   |         |
|                           |         |         | ococcal |         |
|                           |         |         | Infec   |         |
|                           |         |         | tions** |         |
+---------------------------+---------+---------+---------+---------+
|                           | *       | *       | *       | *       |
|                           | *14-5a. | *14-5b. | *14-5c. | *14-5d. |
|                           | Under   | Aged 65 | Under   | Aged 65 |
|                           | Age 5   | Years   | Age 5   | Years   |
|                           | Years** | and     | Years** | and     |
|                           |         | Older** |         | Older** |
+---------------------------+---------+---------+---------+---------+
|                           | Rate    |         |         |         |
|                           | per     |         |         |         |
|                           | 100,000 |         |         |         |
+---------------------------+---------+---------+---------+---------+
| **TOTAL**                 | 76      | 62      | 16      | 9       |
+---------------------------+---------+---------+---------+---------+
| **Race and ethnicity**    |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > American Indian or      | DSU     | DSU     | DSU     | DSU     |
| > Alaska Native           |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Asian or Pacific        | 58      | DSU     | DSU     | DSU     |
| > Islander                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Asian                   | DSU     | DSU     | DSU     | DSU     |
+---------------------------+---------+---------+---------+---------+
| > Native Hawaiian and     | DSU     | DSU     | DSU     | DSU     |
| > other Pacific Islander  |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Black or African        | 154     | 83      | 20      | 9       |
| > American                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > White                   | 63      | 61      | 17      | 9       |
+---------------------------+---------+---------+---------+---------+
|                           |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Hispanic or Latino      | 59      | 43      | 7       | DSU     |
+---------------------------+---------+---------+---------+---------+
| > Not Hispanic or Latino  | DSU     | DSU     | DSU     | DSU     |
+---------------------------+---------+---------+---------+---------+
| > Black or African\       | DSU     | DSU     | DSU     | DSU     |
| > American                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > White                   | DNC     | DNC     | DNC     | DNC     |
+---------------------------+---------+---------+---------+---------+
| **Gender**                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Female                  | 69      | 61      | 14      | 9       |
+---------------------------+---------+---------+---------+---------+
| > Male                    | 84      | 62      | 17      | 9       |
+---------------------------+---------+---------+---------+---------+
| **Family income level**   |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Poor                    | DNC     | DNC     | DNC     | DNC     |
+---------------------------+---------+---------+---------+---------+
| > Near poor               | DNC     | DNC     | DNC     | DNC     |
+---------------------------+---------+---------+---------+---------+
| > Middle/high income      | DNC     | DNC     | DNC     | DNC     |
+---------------------------+---------+---------+---------+---------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

The number of invasive penicillin-resistant pneumococcal infections can
be reduced by lowering the proportion of invasive pneumococcal
infections due to drug-resistant strains or by decreasing invasive
pneumococcal infections in general. The objectives for specific age
groups address the key age groups at risk for invasive pneumococcal
infections. Among children under age 5 years, promoting judicious
antibiotic use may reverse the current trends toward increasing
proportions of infections being caused by drug-resistant strains. For
adults aged 65 years and older, licensure and widespread use of
pneumococcal conjugate vaccines by 2010 could reduce dramatically all
invasive pneumococcal infections, and judicious antibiotic use may have
some impact on the proportion of pneumococcal infections caused by
drug-resistant strains. In this age group, a much greater impact
potentially is achievable through improved use of licensed 23-valent
pneumococcal polysaccharide vaccine for the prevention of invasive
pneumococcal disease. Increasing the use of this vaccine for elderly
persons could have a beneficial impact on the rate of drug-resistant
invasive pneumococcal infections.

### Diseases Preventable Through Targeted Vaccination

14-6. Reduce hepatitis A.

**Target:** 4.5 new cases per 100,000 population.

**Baseline:** 11.3 new cases of hepatitis A per 100,000 population were
reported\
in 1997.

**Target setting method:** Better than the best.

**Data source:** National Notifiable Disease Surveillance System
(NNDSS), CDC, EPO.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1997**                     | **New Hepatitis A   |
|                                                | Cases**             |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| **TOTAL**                                      | 11.3                |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 23.1                |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 4.6                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 6.0                 |
+------------------------------------------------+---------------------+
| > White                                        | 8.1                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 24.2                |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 9.8                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 6.3                 |
+------------------------------------------------+---------------------+
| > White                                        | 7.3                 |
+------------------------------------------------+---------------------+
| ###### Gender                                  |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 8.1                 |
+------------------------------------------------+---------------------+
| > Male                                         | 12.8                |
+------------------------------------------------+---------------------+
| ###### Family income level                     |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+
| ###### Sexual orientation                      | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The health status objectives for hepatitis A virus (HAV) will not be
achieved until a vaccination strategy is implemented that produces high
levels of immunity in children. Children have the highest rates of
hepatitis A and are a primary source for new infections in the
community. In 1999, the Advisory Committee on Immunization Practices
(ACIP) recommended routine hepatitis A vaccination for children living
in States with consistently elevated rates of hepatitis A as the
approach most likely to prevent and control transmission of HAV.Error:
Reference source not found Hepatitis A vaccine is included in the
Vaccines for Children program. Incorporation of hepatitis A vaccine into
the routine childhood vaccination schedule would facilitate
implementation of these recommendations, but data are needed to
determine the appropriate dose and timing of vaccination in the first or
second year of life. Implementation of the recommendations also would be
enhanced by the development of vaccines that combine HAV antigen with
other antigens.

Although routine immunization of children is the approach most likely to
decrease significantly the overall rates of hepatitis A in a community,
it may take some time before the impact of implementing these programs
is measurable. In the interim, persons in groups at high risk of HAV
infection should be vaccinated routinely. These groups include:

-   Illicit drug users.

-   Men who have sex with men.

-   Persons traveling to HAV-endemic countries (see objective 14-15).

-   Persons with occupational risk of infection---that is, persons who
    work with HAV-infected primates or with HAV in a research
    laboratory. No other occupational groups have been shown to be at
    increased risk of exposure.

-   Persons with chronic liver disease.

14-7. Reduce meningococcal disease.

**Target:** 1.0 new cases per 100,000 population.

**Baseline:** 1.3 new cases of meningococcal disease per 100,000
population were reported in 1997.

**Target setting method:** Better than the best.

**Data sources:** Active Bacterial Core Surveillance (ABCs), Emerging
Infections Program Network, CDC, NCID; National Notifiable Diseases
Surveillance System (NNDSS)**,** CDC, EPO.

+------------------------------------------------+---------------------+
| **Total Population, 1997**                     | **New Cases of      |
|                                                | Meningococcal       |
|                                                | Disease**           |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| **TOTAL**                                      | 1.3                 |
+------------------------------------------------+---------------------+
| ###### Race and ethnicity                      |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific\           | DNC                 |
| > Islander                                     |                     |
+------------------------------------------------+---------------------+
| > Black or African American                    | 1.9                 |
+------------------------------------------------+---------------------+
| > White                                        | 1.2                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| Not Hispanic or Latino                         | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNC                 |
+------------------------------------------------+---------------------+
| > White                                        | DNC                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 1.2                 |
+------------------------------------------------+---------------------+
| > Male                                         | 1.3                 |
+------------------------------------------------+---------------------+
| ###### Family income level                     |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

The polysaccharide meningococcal vaccine currently available in the
United States is recommended for certain high-risk groups (people with
asplenia), for laboratory personnel routinely exposed to *Neisseria
meningitidis*, and for travelers to regions where meningococcal disease
is hyperendemic or epidemic (the African "meningitis belt"). Routine
vaccination of civilians is not recommended because of its relative
ineffectiveness in children under age 2 years (among whom risk of
endemic disease is highest) and its relatively short duration of
protection. The vaccine is useful for controlling serogroup C
meningococcal epidemics; these account, however, for less than 5 percent
of the cases of meningococcal disease that occur each year in the United
States. The vaccine provides no protection against serogroup B
meningococci, which account for approximately one-third of the disease
overall in the United States.

New meningococcal conjugate vaccines against serogroups C and Y, which
account for two-thirds of current disease, now are undergoing clinical
trials. Soon they should be available for incorporation into routine
childhood immunization as well as for vaccination of high-risk groups,
possibly including college students. Similar to Hib conjugate vaccines,
new meningococcal conjugate vaccines are expected to be effective in
children.

Development and licensing of new serogroup B meningococcal vaccines also
will help reduce meningococcal disease.

14-8. Reduce Lyme disease.

**Target:** 9.7 new cases per 100,000 population in endemic States.

**Baseline:** 17.4 new cases of Lyme disease per 100,000 population
were\
reported in 1992--96.

**Target setting method:** 44 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** National Notifiable Disease Surveillance System
(NNDSS), CDC, EPO.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1992--96**                 | **New Cases of Lyme |
|                                                | Disease**           |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| **TOTAL**                                      | 17.4                |
+------------------------------------------------+---------------------+
| ###### Race and ethnicity                      |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 17.2\*              |
+------------------------------------------------+---------------------+
| > Male                                         | 19.2\*              |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Note: Data do not include Pennsylvania.

Note: The table above may have continued from the previous page.

In 1991, a standardized case definition for Lyme disease was adopted by
the Council of State and Territorial Epidemiologists. Since then, the
number of reported cases of Lyme disease has increased from 8,257 in
1993 to 16,455 in 1996\
because of increased surveillance as well as a true increase in new
cases. From 1992 through 1996, 92 percent of cases were reported from 10
endemic States. New initiatives to prevent Lyme disease include the
implementation of community-based prevention programs, host-targeted
acaricides to reduce the numbers of vector ticks, and appropriate use of
Lyme disease vaccine.

### Infectious Diseases and Emerging Antimicrobial Resistance

14-9. Reduce hepatitis C.

**Target:** 1 new case per 100,000 population.

**Baseline:** 2.4 new cases of hepatitis C per 100,000 population in
selected\
counties were reported in 1996.

**Target setting method:** Better than the best.

**Data source:** Sentinel Counties Study of Viral Hepatitis, CDC, NCID.

+------------------------------------------------+---------------------+
| **Total Population, 1996**                     | **New Hepatitis C   |
|                                                | Cases**             |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| **TOTAL**                                      | 2.4                 |
+------------------------------------------------+---------------------+
| ###### Race and ethnicity                      |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DNC                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | 3.0                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 2.0                 |
+------------------------------------------------+---------------------+
| > Male                                         | 2.8                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Data represent rates based on estimates from selected counties.

Hepatitis C virus (HCV) is the most common chronic bloodborne viral
infection in the United States.[^44] This virus usually is transmitted
through large or repeated percutaneous exposures to blood---for example,
through sharing of equipment between injection drug users. HCV infects
persons of all ages, but most new cases are among young adults aged 20
to 39 years. The highest proportion of new cases is among whites, but
the highest rates of new cases are among nonwhite racial and ethnic
groups.

14-10. (Developmental) Increase the proportion of persons with chronic
hepatitis C infection identified by State and local health departments.

**Potential data sources:** State health department databases of persons
with HCV infection; National Health and Nutrition Examination Survey
(NHANES), CDC, NCHS.

An estimated 2.7 million persons in the United States are infected
chronically with HCV. Although the annual number of newly acquired HCV
infections has declined from an estimated 180,000 in the mid-1980s to an
estimated 28,000 in 1995, this reservoir of chronically infected persons
can transmit the virus to others, and all of them are at risk for the
severe consequences of chronic liver disease. Because of the large
number of people with chronic HCV infection, identification of these
persons must be a major focus of a comprehensive prevention strategy.
Identification of HCV-infected persons allows (1) counseling to prevent
further HCV transmission, (2) vaccination against HAV and HBV to prevent
additional liver damage, (3) evaluation for chronic liver disease, (4)
possible antiviral therapy, and (5) counseling to avoid potential
hepatotoxins, such as alcohol, that may increase the severity of
HCV-related liver disease.

14-11. Reduce tuberculosis.

**Target:** 1.0 new case per 100,000 population.

**Baseline:** 6.8 new cases of tuberculosis per 100,000 population were
reported\
in 1998.

**Target setting method:** Better than the best.

**Data source:** National TB Surveillance System, CDC, NCHSTP.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1998**                     | **New Tuberculosis  |
|                                                | Cases**             |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| **TOTAL**                                      | 6.8                 |
+------------------------------------------------+---------------------+
| ###### Race and ethnicity                      |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 11.2                |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 34.9                |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 17.4                |
+------------------------------------------------+---------------------+
| > White                                        | 3.8                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 13.6                |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | 5.9                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 17.8                |
+------------------------------------------------+---------------------+
| > White                                        | 2.3                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 5.0                 |
+------------------------------------------------+---------------------+
| > Male                                         | 8.6                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The 1989 *Strategic Plan for the Elimination of TB in the United
States*[^45] set a tuberculosis elimination goal of reducing TB to 1 new
case per million by 2010, with an interim goal of 3.5 cases per 100,000
population by 2000. However, in the mid-1980s the trend toward TB
elimination was reversed, and drug-resistant strains emerged that were
even more deadly. TB cases increased by 20 percent between 1985 and
1992. Renewed efforts to combat the resurgence included improving
laboratories, strengthening surveillance and expanding directly observed
therapy, and expediting investigation of close contacts of TB patients.
From 1993 through 1998, new cases of TB again declined, although the
resurgence and related outbreaks set back TB elimination efforts by
about a decade. Elimination of TB depends on significant effort and
cooperation between public and private health care providers and
agencies at the Federal, State, and local levels.

14-12. Increase the proportion of all tuberculosis patients who complete
curative therapy within 12 months.

**Target:** 90 percent of patients.

**Baseline:** 74 percent of those tuberculosis patients reported in 1996
and started on therapy completed therapy within 12 months.

**Target setting method:** Better than the best.

**Data source:** National TB Surveillance System, CDC, NCHSTP.

Note: The table below may continue to the following page.

+-------------------------------------------------+--------------------+
| **Tuberculosis Patients, 1996**                 | **Completed\       |
|                                                 | Curative Therapy   |
|                                                 | Within 12 Months** |
+=================================================+====================+
|                                                 | Percent            |
+-------------------------------------------------+--------------------+
| **TOTAL**                                       | 74                 |
+-------------------------------------------------+--------------------+
| **Race and ethnicity**                          |                    |
+-------------------------------------------------+--------------------+
| > American Indian or Alaska Native              | 82                 |
+-------------------------------------------------+--------------------+
| > Asian or Pacific Islander                     | 75                 |
+-------------------------------------------------+--------------------+
| > Asian                                         | DNC                |
+-------------------------------------------------+--------------------+
| > Native Hawaiian and other Pacific Islander    | DNC                |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 72                 |
+-------------------------------------------------+--------------------+
| > White                                         | 74                 |
+-------------------------------------------------+--------------------+
|                                                 |                    |
+-------------------------------------------------+--------------------+
| > Hispanic or Latino                            | 73                 |
+-------------------------------------------------+--------------------+
| > Not Hispanic or Latino                        | 74                 |
+-------------------------------------------------+--------------------+
| > Black or African American                     | 72                 |
+-------------------------------------------------+--------------------+
| > White                                         | 75                 |
+-------------------------------------------------+--------------------+
| ###### Gender                                   |                    |
+-------------------------------------------------+--------------------+
| > Female                                        | 75                 |
+-------------------------------------------------+--------------------+
| > Male                                          | 73                 |
+-------------------------------------------------+--------------------+
| **Family income level**                         |                    |
+-------------------------------------------------+--------------------+
| > Poor                                          | DNC                |
+-------------------------------------------------+--------------------+
| > Near poor                                     | DNC                |
+-------------------------------------------------+--------------------+
| > Middle/high income                            | DNC                |
+-------------------------------------------------+--------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The highest priority for TB control is to ensure that persons with the
disease complete curative therapy. If treatment is not continued for a
sufficient length of time, such persons often become ill and contagious
again. Completion of therapy is essential to prevent transmission of the
disease as well as to prevent outbreaks and the development and spread
of drug-resistant TB.

Current therapy guidelines recommend that patients with drug-susceptible
TB should complete a successful regimen within 12 months.[^46]
Multidrug-resistant TB presents difficult treatment problems, often
requiring consultation with a TB specialist and longer treatment
regimens. The measurement of completion of therapy is a long-accepted
indicator of the effectiveness of community TB control efforts. Health
departments traditionally have reported completion-of-therapy results to
CDC and have used this information locally and statewide as an
evaluation\
measure.

14-13. Increase the proportion of contacts and other high-risk persons
with latent tuberculosis infection who complete\
a course of treatment.

**Target:** 85 percent.

**Baseline:** 62 percent of tuberculosis contacts and other high-risk
persons who started on treatment for latent TB infection in 1997
completed treatment.

**Target setting method:** 27 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** Aggregate Reports for TB Reports Evaluation, CDC,
NCHSTP.

> **Data for population groups currently are not collected.**

Treatment for latent TB infection substantially reduces the risk that TB
infection will progress to disease. Certain groups are at very high risk
of developing TB disease once infected. Identifiable population groups
at high risk for TB vary in time and geographic area, depending on
unique and changing TB-related demographics.[^47]

14-14. Reduce the average time for a laboratory to confirm and report
tuberculosis cases.

**Target:** 2 days for 75 percent of cases.

**Baseline:** 21 days were needed for a laboratory to confirm and report
75 percent of TB cases in 1996.

**Target setting method:** 90 percent improvement.

**Data source:** Survey of State Public Health Laboratories, CDC,
NCHSTP.

Commercially available nucleic acid amplification tests are capable of
detecting *Mycobacterium* *tuberculosis* in a specimen within 48 hours
of receipt. Concerns regarding sensitivity, cost, quality control, and
special expertise requirements prevent widespread use of such tests.
Upgrading TB laboratory capabilities and facilities, improving training
in state-of-the-art mycobacteriology, and evaluating proficiency should
better enable State public health laboratories to apply these new rapid
tests to the diagnosis of TB.

14-15. (Developmental) Increase the proportion of international
travelers who receive recommended preventive services when traveling in
areas of risk for select infectious\
diseases: hepatitis A, malaria, and typhoid.

**Potential data source:** *Abstract of International Travel to and from
the United States*, U.S. Department of Commerce.

The number of international travelers from the United States has
increased an average of 3 percent a year for the past decade. The three
diseases highlighted in this objective---hepatitis A, malaria, and
typhoid---account for a large proportion of illness and disability for
international travelers. Before embarking, some travelers go to a travel
clinic, some visit primary care providers, and some receive no pretravel
care.

An appropriate prescription of antimalarial prophylaxis medications
constitutes recommended preventive services for this disease. Risk areas
can be identified by referencing the malaria section in the most recent
edition of *Health Information for International Travel*.

14-16. Reduce invasive early onset group B streptococcal\
disease.

**Target:** 0.5 new cases per 1,000 live births.

**Baseline:** 1.0 new case of invasive early onset group B streptococcal
disease per 1,000 live births was reported in 1996.

**Target setting method:** Better than the best.

**Data source:** Active Bacterial Core Surveillance (ABCs), Emerging
Infections Program Network, CDC, NCID.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Live Births, 1996**                          | **New Cases of      |
|                                                | Group B\            |
|                                                | Streptococcal\      |
|                                                | Disease**           |
+================================================+=====================+
|                                                | Rate per 1,000      |
+------------------------------------------------+---------------------+
| **TOTAL**                                      | 1.0                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 1.5                 |
+------------------------------------------------+---------------------+
| > White                                        | 1.0                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | DNA                 |
+------------------------------------------------+---------------------+
| > Male                                         | DNA                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The number of new cases of early onset group B streptococcal (GBS)
disease in 1996 reflected a substantial decline from earlier years,
before intervention became common practice. GBS causes bloodstream
infections and meningitis in babies. Additional prevention is possible,
because occurrence of the disease is more likely to reflect ineffective
prevention efforts than antibiotic failures. In certain areas, rates
approximating 0.5 per 1,000 births already have been achieved. Although
these data may represent the background rate of nonpreventable cases,
most geographic areas should be able to achieve the same low rates. The
racial disparity in rates will be eliminated with more aggressive use of
prevention protocols.

African Americans consistently have had higher rates of GBS diseases
than other races. Implementation of GBS prevention policies is expected
to eliminate the disparity. Thus, the target of 0.5 new cases per 1,000
births is one that can be obtained in all geographic areas and all
racial and ethnic groups. By the year 2010, reductions in early onset
disease might be the result of both improved use of intrapartum
antibiotic prophylaxis and implementation of GBS conjugate vaccines
currently in clinical trials.

14-17. Reduce hospitalizations caused by peptic ulcer disease\
in the United States.

**Target:** 46 hospitalizations per 100,000 population.

**Baseline:** 71 hospitalizations per 100,000 population occurred in
1998 (age\
adjusted to the year 2000 standard population).

**Target setting method:** Better than the best.

**Data source:** National Hospital Discharge Survey (NHDS), CDC, NCHS.

+---------------------------------------------+------------------------+
| **Total Population, 1998**                  | **Peptic Ulcer\        |
|                                             | Hospitalizations**     |
+=============================================+========================+
|                                             | Rate per 100,000       |
+---------------------------------------------+------------------------+
| **TOTAL**                                   | 71                     |
+---------------------------------------------+------------------------+
| ###### Race and ethnicity                   |                        |
+---------------------------------------------+------------------------+
| > American Indian or Alaska Native          | DSU                    |
+---------------------------------------------+------------------------+
| > Asian or Pacific Islander                 | DSU                    |
+---------------------------------------------+------------------------+
| > Asian                                     | DNC                    |
+---------------------------------------------+------------------------+
| > Native Hawaiian and other Pacific\        | DNC                    |
| > Islander                                  |                        |
+---------------------------------------------+------------------------+
| > Black or African American                 | 80                     |
+---------------------------------------------+------------------------+
| > White                                     | 52                     |
+---------------------------------------------+------------------------+
|                                             |                        |
+---------------------------------------------+------------------------+
| > Hispanic or Latino                        | DSU                    |
+---------------------------------------------+------------------------+
| > Not Hispanic or Latino                    | DSU                    |
+---------------------------------------------+------------------------+
| > Black or African American                 | DSU                    |
+---------------------------------------------+------------------------+
| > White                                     | DSU                    |
+---------------------------------------------+------------------------+
| **Gender**                                  |                        |
+---------------------------------------------+------------------------+
| > Female                                    | 64                     |
+---------------------------------------------+------------------------+
| > Male                                      | 79                     |
+---------------------------------------------+------------------------+
| ###### Family income level                  |                        |
+---------------------------------------------+------------------------+
| > Poor                                      | DNC                    |
+---------------------------------------------+------------------------+
| > Near poor                                 | DNC                    |
+---------------------------------------------+------------------------+
| > Middle/high income                        | DNC                    |
+---------------------------------------------+------------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: Age adjusted to the year 2000 standard population.

Peptic ulcer disease affects up to 25 million persons in the United
States and causes up to 6,500 deaths each year. Until recently, peptic
ulcers were thought to be caused by stress, spicy foods, and excess
stomach acid. Most patients were treated with antacids or acid-reducing
medications, and recurrences were the rule after therapy was
discontinued. The discovery in the 1980s that a bacterial organism,
*Helicobacter pylori (H. pylori)*, causes up to 90 percent of peptic
ulcers has changed the way ulcers are evaluated and managed.[^48]**^,^**
[^49] Now appropriate antibiotic regimens successfully eradicate the
infection and prevent recurrence and complications such as bleeding or
perforation.

Despite extensive scientific data linking peptic ulcer disease to *H.
pylori*, studies indicate that many health care providers and consumers
are unaware of the relationship, and many persons with ulcers do not
receive appropriate therapy.[^50]**^,^** [^51]\
A campaign to educate health care providers and consumers about *H.
pylori* and its link to peptic ulcer disease was initiated in 1997. The
Centers for Disease Control and Prevention (CDC) and Partnership *H.
pylori* Educational Campaign includes partners from academic
institutions, government agencies, and industry.[^52] The increased
awareness of the link between *H. pylori* and ulcers among health care
providers and consumers is expected to lead to the increased use of
appropriate antibiotics. This improved treatment, if available to those
who need it, should decrease hospitalization rates---an indicator for
severe illness and disability---due to peptic ulcer disease and its
complications.

14-18. Reduce the number of courses of antibiotics for ear\
infections for young children.

**Target:** 88 antibiotic courses per 100 children under age 5 years.

**Baseline:** 108 antibiotic courses for otitis media per 100 children
under age 5 years were prescribed during 1996--97 (2-year average).

**Target setting method:** 19 percent improvement.

**Data sources:** National Ambulatory Medical Care Survey (NAMCS), CDC,
NCHS; National Hospital Ambulatory Medical Care Survey (NHAMCS), CDC,
NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Children Under Age 5 Years, 1996--97**       | **Courses of\       |
|                                                | Antibiotics for Ear |
|                                                | Infections**        |
+================================================+=====================+
|                                                | Rate per 100        |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 108                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 84                  |
+------------------------------------------------+---------------------+
| > White                                        | 116                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 107                 |
+------------------------------------------------+---------------------+
| > Male                                         | 109                 |
+------------------------------------------------+---------------------+
| ###### Family income level                     |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Antibiotic courses for otitis media, commonly called ear infection, can
be reduced through two methods. A portion of otitis media cases---otitis
media with effusion rather than acute otitis media---do not require
antimicrobial treatment. A national campaign for judicious antibiotic
use aims to reduce inappropriate antibiotic treatment for this portion
of otitis media.[^53] The leading cause of otitis media is pneumococcus.
Preventing pneumococcal otitis media is expected to be possible
following licensure of pneumococcal conjugate vaccines. (See Focus Area
28. Vision and Hearing.)

14-19. Reduce the number of courses of antibiotics prescribed\
for the sole diagnosis of the common cold.

**Target:** 1,268 antibiotic courses per 100,000 population.

**Baseline:** 2,535 antibiotic courses per 100,000 population were
prescribed for the sole diagnosis of the common cold, 1996--97.

**Target setting method:** 50 percent improvement.

**Data sources:** National Ambulatory Medical Care Survey (NAMCS), CDC,
NCHS; National Hospital Ambulatory Medical Care Survey (NHAMCS), CDC,
NCHS.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1996--97**                 | **Courses of\       |
|                                                | Antibiotics for     |
|                                                | Common Cold**       |
+================================================+=====================+
|                                                | Rate per 100,000    |
+------------------------------------------------+---------------------+
| **TOTAL**                                      | 2,535               |
+------------------------------------------------+---------------------+
| ###### Race and ethnicity                      |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DSU                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DSU                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | 2,431               |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DSU                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DSU                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DSU                 |
+------------------------------------------------+---------------------+
| > White                                        | DSU                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 2,644               |
+------------------------------------------------+---------------------+
| > Male                                         | 2,421               |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The common cold does not require antimicrobial therapy. Inappropriate
therapy for the common cold can be reduced by 50 percent by promoting
judicious anti-microbial use, provided that caregivers and patients
accept that antibiotics are ineffective in treating colds. Effective
programs for the judicious use of antibiotics could help reduce the
prescription of antibiotics for the common cold.

14-20. Reduce hospital-acquired infections in intensive care\
unit patients.

Target and baseline:

  ------------- ----------------------------- --------------- ---------------
  Objective     Reduction in                  1998\           2010\
                Hospital-Acquired Infections  Baseline        Target
                in Intensive Care Units                       

                                              *Infections per 
                                              1,000 Days'     
                                              Use*            

                **Intensive care unit                         
                patients**                                    

  **14-20a.**   Catheter-associated urinary   5.9             5.3
                tract infection                               

  **14-20b.**   Central line-associated       5.3             4.8
                bloodstream infection                         

  **14-20c.**   Ventilator-associated         11.1            10.0
                pneumonia                                     

                **Infants weighing 1,000                      
                grams\                                        
                or less at birth in intensive                 
                care**                                        

  **14-20d.**   Central line-associated       12.2            11.0
                bloodstream infection                         

  **14-20e.**   Ventilator-associated         4.9             4.4
                pneumonia                                     
  ------------- ----------------------------- --------------- ---------------

**Target setting method:** 10 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** National Nosocomial Infections Surveillance System
(NNIS), CDC, NCID.

> **Data for population groups currently are not collected.**

Hospital-acquired infections are a leading cause of illness and death in
the United States. Each year, 36 million patients are admitted to U.S.
hospitals.[^54] Annually, more than 500,000 of the nearly 2 million
patients stricken with a hospital-acquired infection are intensive care
patients. Of the total, nearly 90,000 die. The annual cost of
hospital-acquired infections is approximately \$4.5 billion a year. In
the past 20 years, the rate of hospital-acquired infections has
increased 36 percent.

The rate of hospital-acquired infections has increased largely because
hospital patients of the late 1990s on average were older and sicker
than those of 20 years earlier and thus more susceptible to infection,
and also because medical advances that can save or prolong lives may
carry risks for infections. Because both trends are expected to
continue, only a modest reduction in the number of new cases of
infections can be expected; however, a small reduction will save
thousands of lives.

14-21. Reduce antimicrobial use among intensive care unit\
patients.

**Target:** 120 daily doses per 1,000 patient days.

**Baseline:** 150 daily doses of antimicrobials per 1,000 patient days
were used among intensive care unit patients in 1995.

**Target setting method:** 20 percent improvement.

**Data source:** National Nosocomial Infections Surveillance System
(NNIS), CDC, NCID.

Hospital-acquired infections caused by antimicrobial-resistant pathogens
can be virtually untreatable. Further, antimicrobial resistance that
develops in the hospital can spread into the community and has the
potential to cause a public health disaster. Excessive or inappropriate
use of antimicrobials or both, which occur most frequently in intensive
care units (ICUs), is the major cause of antimicrobial resistance.
Research indicates that antibiotics are being used more often than
hospital prescription guidelines recommend. For example, one study in
the late 1990s indicated that as much as 60 percent of the hospital
prescriptions for vancomycin are not in accordance with the guidelines.
Decreasing the use of antimicrobials, especially in ICUs, is the
critical step in reducing the public threat of antimicrobial resistance.
Studies have shown that interventions in individual hospitals have
achieved reductions of 20 percent or more in antimicrobial use.

### Vaccination Coverage and Strategies

14-22. Achieve and maintain effective vaccination coverage levels for
universally recommended vaccines among young\
children.

**Target and baseline**:

+----------+---------------------------------+------------+------------+
| O        | Increase in and Maintenance of\ | 1998\      | 2010\      |
| bjective | Vaccination Coverage Levels\    | Baseline   | Target     |
|          | Among Children Aged 19 to 35    |            |            |
|          | Months                          |            |            |
+----------+---------------------------------+------------+------------+
|          |                                 | #######    |            |
|          |                                 | ## Percent |            |
+----------+---------------------------------+------------+------------+
| **1      | 4 doses                         | 84         | 90         |
| 4-22a.** | diphtheria-tetanus-acellular    |            |            |
|          | pertussis (DTaP) vaccine        |            |            |
+----------+---------------------------------+------------+------------+
| **1      | 3 doses *Haemophilus            | 93         | 90         |
| 4-22b.** | influenzae* type b (Hib)        |            |            |
|          | vaccine                         |            |            |
+----------+---------------------------------+------------+------------+
| **1      | 3 doses hepatitis B (hep B)     | 87         | 90         |
| 4-22c.** | vaccine                         |            |            |
+----------+---------------------------------+------------+------------+
| **1      | 1 dose measles-mumps-rubella    | 92         | 90         |
| 4-22d.** | (MMR) vaccine                   |            |            |
+----------+---------------------------------+------------+------------+
| **1      | 3 doses polio vaccine           | 91         | 90         |
| 4-22e.** |                                 |            |            |
+----------+---------------------------------+------------+------------+
| **1      | 1 dose varicella vaccine        | 43         | 90         |
| 4-22f.** |                                 |            |            |
+----------+---------------------------------+------------+------------+

**Target setting method:** Consistent with the Childhood Immunization
Initiative.

**Data source:** National Immunization Survey (NIS), CDC, NCHS and NIP.

Note: The table below may continue to the following page.

<table>
<colgroup>
<col style="width: 28%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 11%" />
</colgroup>
<thead>
<tr class="header">
<th rowspan="3"><strong>Children Aged<br />
19 to 35 Months, 1998</strong></th>
<th colspan="11"><strong>Vaccination Coverage</strong></th>
</tr>
<tr class="odd">
<th><strong>14-22a.<br />
4<br />
Doses DTaP</strong></th>
<th colspan="2"><strong>14-22b.<br />
3<br />
Doses Hib</strong></th>
<th colspan="2"><strong>14-22c.<br />
3<br />
Doses Hep B</strong></th>
<th colspan="2"><strong>14-22d.<br />
1<br />
Dose MMR</strong></th>
<th colspan="3"><strong>14-22e.<br />
3<br />
Doses<br />
Polio</strong></th>
<th><strong>14-22f.<br />
1<br />
Dose Vari-cella</strong></th>
</tr>
<tr class="header">
<th colspan="11">Percent</th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td><strong>TOTAL</strong></td>
<td colspan="2">84</td>
<td colspan="2">93</td>
<td colspan="2">87</td>
<td colspan="2">92</td>
<td>91</td>
<td colspan="2">43</td>
</tr>
<tr class="even">
<td colspan="12"><h6 id="race-and-ethnicity-7">Race and
ethnicity</h6></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>American Indian or Alaska Native</p>
</blockquote></td>
<td colspan="2">78</td>
<td colspan="2">92</td>
<td colspan="2">80</td>
<td colspan="2">86</td>
<td>83</td>
<td colspan="2">33</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Asian or Pacific<br />
Islander</p>
</blockquote></td>
<td colspan="2">87</td>
<td colspan="2">93</td>
<td colspan="2">90</td>
<td colspan="2">93</td>
<td>94</td>
<td colspan="2">57</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Asian</p>
</blockquote></td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td>DNC</td>
<td colspan="2">DNC</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Native Hawaiian and other<br />
Pacific Islander</p>
</blockquote></td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td>DNC</td>
<td colspan="2">DNC</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Black or African<br />
American</p>
</blockquote></td>
<td colspan="2">77</td>
<td colspan="2">90</td>
<td colspan="2">84</td>
<td colspan="2">89</td>
<td>88</td>
<td colspan="2">43</td>
</tr>
<tr class="even">
<td><blockquote>
<p>White</p>
</blockquote></td>
<td colspan="2">86</td>
<td colspan="2">94</td>
<td colspan="2">88</td>
<td colspan="2">93</td>
<td>92</td>
<td colspan="2">43</td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Hispanic or Latino</p>
</blockquote></td>
<td colspan="2">80</td>
<td colspan="2">92</td>
<td colspan="2">86</td>
<td colspan="2">91</td>
<td>89</td>
<td colspan="2">47</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Not Hispanic or<br />
Latino</p>
</blockquote></td>
<td colspan="2">85</td>
<td colspan="2">94</td>
<td colspan="2">87</td>
<td colspan="2">92</td>
<td>91</td>
<td colspan="2">42</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Black or African American</p>
</blockquote></td>
<td colspan="2">77</td>
<td colspan="2">90</td>
<td colspan="2">84</td>
<td colspan="2">89</td>
<td>88</td>
<td colspan="2">42</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>White</p>
</blockquote></td>
<td colspan="2">87</td>
<td colspan="2">95</td>
<td colspan="2">88</td>
<td colspan="2">93</td>
<td>92</td>
<td colspan="2">42</td>
</tr>
<tr class="even">
<td colspan="12"><h6 id="gender-3">Gender</h6></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Female</p>
</blockquote></td>
<td colspan="2">84</td>
<td colspan="2">94</td>
<td colspan="2">87</td>
<td colspan="2">92</td>
<td>91</td>
<td colspan="2">43</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Male</p>
</blockquote></td>
<td colspan="2">84</td>
<td colspan="2">93</td>
<td colspan="2">87</td>
<td colspan="2">92</td>
<td>90</td>
<td colspan="2">43</td>
</tr>
<tr class="odd">
<td colspan="12"><h6 id="family-income-level-4">Family income
level</h6></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Poor</p>
</blockquote></td>
<td colspan="2">81</td>
<td colspan="2">92</td>
<td colspan="2">86</td>
<td colspan="2">91</td>
<td>90</td>
<td colspan="2">46</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Near poor</p>
</blockquote></td>
<td colspan="2">83</td>
<td colspan="2">92</td>
<td colspan="2">87</td>
<td colspan="2">91</td>
<td>91</td>
<td colspan="2">42</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Middle/high<br />
income</p>
</blockquote></td>
<td colspan="2">89</td>
<td colspan="2">96</td>
<td colspan="2">89</td>
<td colspan="2">94</td>
<td>92</td>
<td colspan="2">49</td>
</tr>
<tr class="odd">
<td colspan="12"><h6 id="disability-status">Disability status</h6></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Persons with<br />
disabilities</p>
</blockquote></td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td>DNC</td>
<td colspan="2">DNC</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Persons without disabilities</p>
</blockquote></td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td colspan="2">DNC</td>
<td>DNC</td>
<td colspan="2">DNC</td>
</tr>
</tbody>
</table>

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Vaccination coverage levels of 90 percent are, in general, sufficient to
prevent circulation of viruses and bacteria-causing vaccine-preventable
diseases.[^55]**^,^** [^56] Maintenance of high vaccination coverage
levels in early childhood is the best way to prevent the spread of VPDs
in childhood and to provide the foundation for controlling VPDs among
adults. Diseases that affect humans only may eventually be eradicated or
at least eliminated through high vaccination coverage levels.[^57] These
diseases include polio and measles in the near future and possibly
hepatitis B later on. Although polio eradication is expected to be
certified by the year 2005, vaccine coverage levels will continue to be
assessed until vaccination is no longer recommended. The measles
epidemic of 1989--91 demonstrated that achievement of high coverage
levels at the time of school entry was insufficient to control VPD
outbreaks. Although coverage levels currently are the highest ever
recorded, the United States must continue to ensure that each new cohort
of children is fully vaccinated with all recommended vaccine doses; as
of June 22, 2000, 20 to 24 vaccine doses are recommended through age 16
years, with 16 to 20 doses by age 2 years. Any new universally
recommended vaccine should be at a 90 percent coverage level within 5
years of the recommendation.

Although national coverage levels may exceed 90 percent, variation in
the level of coverage among smaller areas may include subgroups of the
population at substantially lower levels of protection. These subgroups
or pockets of undervaccinated persons make the population vulnerable to
major outbreaks of VPDs. Monitoring of coverage at smaller geographic
levels within the United States helps ensure that these potential
pockets of children are identified to target interventions and reduce
the risk of future disease outbreaks. In addition, each State and major
urban area should aim to achieve 90 percent coverage to ensure uniformly
high vaccination coverage.

14-23. Maintain vaccination coverage levels for children in\
licensed day care facilities and children in kindergarten through the
first grade.

Target and baseline:

+---------+----------------------------+---------------+--------------+
| Ob      | Maintenance of             | 1997--98\     | 2010\        |
| jective | Vaccination\               | Baseline\*    | Target       |
|         | Coverage Levels for        |               |              |
|         | Children                   |               |              |
+---------+----------------------------+---------------+--------------+
|         |                            | ####          |              |
|         |                            | ##### Percent |              |
+---------+----------------------------+---------------+--------------+
|         | **Children in day care**   |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Di                         | 96            | 95           |
| -23a.** | phtheria-tetanus-acellular |               |              |
|         | pertussis (DTaP) vaccine   |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Measles/mumps/rubella      | 89            | 95           |
| -23b.** | vaccines                   |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Polio vaccine              | 96            | 95           |
| -23c.** |                            |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Hepatitis B vaccine        | Developmental |              |
| -23d.** |                            |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Varicella vaccine          | Developmental |              |
| -23e.** |                            |               |              |
+---------+----------------------------+---------------+--------------+
|         | **Children in K through    |               |              |
|         | 1st grade**                |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Di                         | 97            | 95           |
| -23f.** | phtheria-tetanus-acellular |               |              |
|         | pertussis (DTaP) vaccine   |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Measles/mumps/rubella      | 96            | 95           |
| -23g.** | vaccines                   |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Polio vaccine              | 97            | 95           |
| -23h.** |                            |               |              |
+---------+----------------------------+---------------+--------------+
| **14    | Hepatitis B vaccine        | ########      |              |
| -23i.** |                            | Developmental |              |
+---------+----------------------------+---------------+--------------+
| **14    | Varicella vaccine          | Developmental |              |
| -23j.** |                            |               |              |
+---------+----------------------------+---------------+--------------+

\*Weighted means.

**Target setting method:** Consistent with year 2000 target. (Better
than the best will be used when data are available.)

**Data source:** Immunization Program Annual Reports, CDC, NIP.

> **Data for population groups currently are not collected.**

Uniformly high coverage levels are required to prevent circulation of
the viruses and bacteria that cause VPDs. The target level was set to be
consistent with the Healthy People 2000 objective because the
achievement of that objective has resulted in the prevention of disease
spread, and this objective seeks to maintain the high coverage achieved
in these settings.

Entry requirements for school and day care are one of the most effective
interventions the States have at their disposal to ensure that children
are appropriately vaccinated. The impact of entry requirements for
school and day care has been profound---more than 95 percent of children
are vaccinated. Several studies support the role of entry requirements
in increasing vaccination rates and decreasing the rate of new cases of
measles. Strict enforcement of school vaccination requirements has been
shown to play a determining role in lowering new cases of measles.[^58]

14-24. Increase the proportion of young children and adolescents who
receive all vaccines that have been recommended for universal
administration for at least 5 years.

Target and baseline:

+-----------+------------------------------+------------+------------+
| Objective | Increase in Coverage Levels  | 1998\      | 2010\      |
|           | of Universally Recommended\  | Baseline   | Target     |
|           | Vaccines                     |            |            |
+-----------+------------------------------+------------+------------+
|           |                              | #######    |            |
|           |                              | ## Percent |            |
+-----------+------------------------------+------------+------------+
| **        | Children aged 19 to 35       | 73         | 80         |
| 14-24a.** | months who receive the       |            |            |
|           | recommended vaccines (4DTaP, |            |            |
|           | 3 polio, 1 MMR, 3 Hib, 3 hep |            |            |
|           | B)                           |            |            |
+-----------+------------------------------+------------+------------+
| **        | Adolescents aged 13 to 15    | Dev        |            |
| 14-24b.** | years who receive the        | elopmental |            |
|           | recommended\                 |            |            |
|           | vaccines                     |            |            |
+-----------+------------------------------+------------+------------+

**Target setting method:** Better than the best.

**Data source:** National Immunization Survey (NIS), CDC, NCHS and NIP;
National Health Interview Survey (NHIS), CDC, NCHS.

Note: The table below may continue to the following page.

+---------------------------------+-----------------+------------------+
| **Children Aged 19 to 35        | *               |                  |
| Months, 1998**                  | *Vaccinations** |                  |
+=================================+=================+==================+
|                                 | **14-24a.\      | **4 DTaP,\       |
|                                 | 4 DTaP, 3       | 3 Polio,\        |
|                                 | Polio,\         | 1 MMR\***        |
|                                 | 1 MMR, 3 Hib,\  |                  |
|                                 | 3 Hep B**       |                  |
+---------------------------------+-----------------+------------------+
|                                 | Percent         |                  |
+---------------------------------+-----------------+------------------+
| **TOTAL**                       | 73              | 81               |
+---------------------------------+-----------------+------------------+
| **Race and ethnicity**          |                 |                  |
+---------------------------------+-----------------+------------------+
| > American Indian or Alaska     | 65              | 75               |
| > Native                        |                 |                  |
+---------------------------------+-----------------+------------------+
| > Asian or Pacific Islander     | 73              | 82               |
+---------------------------------+-----------------+------------------+
| > Asian                         | DNC             | DNC              |
+---------------------------------+-----------------+------------------+
| > Native Hawaiian and other\    | DNC             | DNC              |
| > Pacific Islander              |                 |                  |
+---------------------------------+-----------------+------------------+
| > Black or African American     | 66              | 74               |
+---------------------------------+-----------------+------------------+
| > White                         | 74              | 82               |
+---------------------------------+-----------------+------------------+
|                                 |                 |                  |
+---------------------------------+-----------------+------------------+
| > Hispanic or Latino            | 69              | 77               |
+---------------------------------+-----------------+------------------+
| > Not Hispanic or Latino        | 74              | 81               |
+---------------------------------+-----------------+------------------+
| > Black or African American     | 67              | 74               |
+---------------------------------+-----------------+------------------+
| > White                         | 76              | 83               |
+---------------------------------+-----------------+------------------+
| ###### Gender {#gender-4}       |                 |                  |
+---------------------------------+-----------------+------------------+
| > Female                        | 72              | 81               |
+---------------------------------+-----------------+------------------+
| > Male                          | 73              | 81               |
+---------------------------------+-----------------+------------------+
| **Family income level**         |                 |                  |
+---------------------------------+-----------------+------------------+
| > Poor                          | 70              | 78               |
+---------------------------------+-----------------+------------------+
| > Near poor                     | 72              | 80               |
+---------------------------------+-----------------+------------------+
| > Middle/high income            | 77              | 85               |
+---------------------------------+-----------------+------------------+
| ###### Disabilit                |                 |                  |
| y status {#disability-status-1} |                 |                  |
+---------------------------------+-----------------+------------------+
| > Persons with disabilities     | DNC             | DNC              |
+---------------------------------+-----------------+------------------+
| > Persons without disabilities  | DNC             | DNC              |
+---------------------------------+-----------------+------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

\*Data for 4 DTaP, 3 polio, and 1 MMR are displayed to further
characterize the issue.

Note: The table above may have continued from the previous page.

Determining whether the population is protected against a VPD is best
evaluated by examining the coverage level of individual vaccines (see
objective 14-22). It is also important to ensure that the health care
system fully vaccinates individual children, providing vaccines that
have been universally recommended for at least 5 years and that are
currently recommended. Changes in the immunization schedule will occur
as new vaccines are added to the list of recommended vaccines and as
vaccines for eradicated diseases are removed from the list.[^59] For
example, polio virus vaccine is not expected to be recommended by the
year 2010. Although monitoring the proportion of children who have
received the combination of four DTaP, three polio, and one MMR will
continue for historical comparison, attention should be focused on the
combination of all universally recommended vaccines.

14-25. Increase the proportion of providers who have measured the
vaccination coverage levels among children in their practice population
within the past 2 years.

Target and baseline:

+-----------+------------------------------+------------+------------+
| Objective | Increase in Providers        | 1997\      | 2010\      |
|           | Measuring\                   | Baseline   | Target     |
|           | Vaccination Levels           |            |            |
+-----------+------------------------------+------------+------------+
|           |                              | #######    |            |
|           |                              | ## Percent |            |
+-----------+------------------------------+------------+------------+
| **        | Public health providers      | 66         | 90         |
| 14-25a.** |                              |            |            |
+-----------+------------------------------+------------+------------+
| **        | Private providers            | 6          | 90         |
| 14-25b.** |                              |            |            |
+-----------+------------------------------+------------+------------+

**Target setting method:** 36 percent improvement for public health
providers; 1,400 percent improvement for private providers.

**Data source:** Immunization Program Annual Reports, CDC, NIP.

In 1997, 66 percent of public health department providers assessed their
vaccination levels.[^60] State immunization programs are collaborating
with private providers to extend provider-based assessments to the
private sector. With the increasing role of managed care and Health Plan
Employer Data and Information Set (HEDIS) measures, private providers
should have additional occasions to examine their coverage levels.

Most providers (public and private) overestimate the vaccination
coverage level they are achieving with their clients.[^61] Assessment of
practice-based coverage levels and feedback of those data to the
providers have been an effective strategy for increasing vaccination of
children served by a given practice.[^62]**^,^** [^63]Managed care
organizations have begun reporting vaccination coverage levels using the
HEDIS criteria as a way of evaluating quality of care.[^64]
Practice-based assessment also has been recommended by ACIP,[^65] the
National Vaccine Advisory Committee, the American Academy of Pediatrics,
and the American Academy of Family Physicians,[^66] as well as the Task
Force for Community Preventive Services.[^67] The Clinic Assessment
Software Application provides a mechanism for assessing levels of
vaccination coverage in a practice and could be used for tracking
patients.

14-26. Increase the proportion of children who participate in fully
operational population-based immunization registries.

**Target:** 95 percent of children under age 6 years.

**Baseline:** 32 percent of children under age 6 years participated in
an immunization registry in 1999.

**Target setting method:** 197 percent improvement. (Better than the
best will be used when data are available.)

**Data source:** Immunization Program Annual Reports, CDC, NIP.

> **Data for population groups currently are not collected.**

A fully operational population-based registry includes capabilities to
(1) protect confidential information, (2) enroll all children at the
State or community level automatically at birth, (3) give providers
access to complete vaccination history, (4) recommend needed
vaccinations, (5) notify children who are due and overdue for
vaccinations, (6) assess practice and geographic-level coverage, and (7)
produce authorized immunization records. Registries may provide other
important functions such as assisting in the evaluation of vaccine
safety. Registries may serve other purposes as well, including VPD
surveillance, vaccine efficacy monitoring, and vaccine inventory
management.

Population-based immunization registries will be a cornerstone of the
Nation's immunization system by 2010. Responsibility for registry
development rests with State and local communities, with assistance from
Federal agencies and private partners. Registries facilitate the timely
vaccination of children by ensuring that the child's complete
vaccination history is available to the health care provider. Registries
are valuable given the mobile nature of today's population and that many
persons do not see the same provider consistently. Registries also can
be used to monitor the vaccination status of populations that are low
income, uninsured, and at greater risk for incomplete vaccination.

Few population-based immunization registries existed at the State or
community level before 1992, and limited data are available regarding
their implementation. A 1999 CDC survey showed immunization registries
are being developed in all States.[^68] Additional efforts are under way
to establish registry links between private providers and immunization
partners such as managed care organizations and WIC programs. Issues
such as privacy, confidentiality, and access of registry data are being
addressed as registries are developed.

Participation in immunization registries will continue to increase. The
development of childhood immunization registries has widespread support
among parents and providers,[^69] and the required technology is
becoming less expensive and simpler. Registries are part of the current
trend to computerize medical data in the United States. To be
successful, registries must be integrated seamlessly into the current
provider environment and create no additional burdens.

14-27. Increase routine vaccination coverage levels for\
adolescents.

Target and baseline:

+-----------+------------------------------+------------+------------+
| Objective | Increase in Vaccination      | 1997\      | 2010\      |
|           | Coverage Levels for          | Baseline\* | Target     |
|           | Adolescents Aged 13 to 15    |            |            |
|           | Years                        |            |            |
+-----------+------------------------------+------------+------------+
|           |                              | #######    |            |
|           |                              | ## Percent |            |
+-----------+------------------------------+------------+------------+
| **        | 3 or more doses of hepatitis | 48         | 90         |
| 14-27a.** | B                            |            |            |
+-----------+------------------------------+------------+------------+
| **        | 2 or more doses of measles,  | 89         | 90         |
| 14-27b.** | mumps, rubella               |            |            |
+-----------+------------------------------+------------+------------+
| **        | 1 or more doses of           | 93         | 90         |
| 14-27c.** | tetanus-diphtheria booster   |            |            |
+-----------+------------------------------+------------+------------+
| **        | 1 or more doses of           | 45         | 90         |
| 14-27d.** | varicella\                   |            |            |
|           | (excluding children who have |            |            |
|           | had varicella)               |            |            |
+-----------+------------------------------+------------+------------+

\*Data primarily are based on parental recall; provider verification has
not occurred.

**Target setting method:** Consistent with target levels established
under\
Childhood Immunization Initiative.

**Data source:** National Health Interview Survey (NHIS), CDC, NCHS.

+---------------------------+---------+---------+---------+---------+
| **Adolescents Aged 13     | **1     | **1     | **1     | **1     |
| Through 15 Years, 1997**  | 4-27a.\ | 4-27b.\ | 4-27c.\ | 4-27d.\ |
|                           | 3 or    | 2 or    | 1 or    | 1 or    |
|                           | More    | More    | More    | More    |
|                           | Doses\  | Doses   | Doses\  | Doses   |
|                           | Hep B** | MMR**   | Teta    | Vari    |
|                           |         |         | nus-Dip | cella** |
|                           |         |         | htheria |         |
|                           |         |         | Bo      |         |
|                           |         |         | oster** |         |
+===========================+=========+=========+=========+=========+
|                           | Percent |         |         |         |
+---------------------------+---------+---------+---------+---------+
| **TOTAL**                 | 48      | 89      | 93      | 45      |
+---------------------------+---------+---------+---------+---------+
| **Race and ethnicity**    |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > American Indian or      | DSU     | DSU     | DSU     | DSU     |
| > Alaska Native           |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Asian or Pacific        | 46      | 90      | 92      | DSU     |
| > Islander                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Asian                   | DSU     | 87      | 90      | DSU     |
+---------------------------+---------+---------+---------+---------+
| > Native Hawaiian and     | DSU     | DSU     | DSU     | DSU     |
| > other Pacific Islander  |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Black or African        | 59      | 88      | 93      | 49      |
| > American                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > White                   | 46      | 89      | 93      | 44      |
+---------------------------+---------+---------+---------+---------+
|                           |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Hispanic or Latino      | 55      | 88      | 91      | 58      |
+---------------------------+---------+---------+---------+---------+
| > Not Hispanic or Latino  | 47      | 89      | 93      | 42      |
+---------------------------+---------+---------+---------+---------+
| > Black or African\       | 59      | 88      | 93      | 49      |
| > American                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > White                   | 44      | 89      | 93      | 40      |
+---------------------------+---------+---------+---------+---------+
| **Gender**                |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Female                  | 49      | 91      | 94      | 41      |
+---------------------------+---------+---------+---------+---------+
| > Male                    | 47      | 88      | 91      | 49      |
+---------------------------+---------+---------+---------+---------+
| **Family income level**   |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Poor                    | 52      | 87      | 93      | 43      |
+---------------------------+---------+---------+---------+---------+
| > Near poor               | 48      | 90      | 91      | 52      |
+---------------------------+---------+---------+---------+---------+
| > Middle/high income      | 43      | 89      | 93      | 45      |
+---------------------------+---------+---------+---------+---------+
| #                         |         |         |         |         |
| ##### Geographic location |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Urban                   | 50      | 90      | 94      | 46      |
+---------------------------+---------+---------+---------+---------+
| > Rural                   | 43      | 87      | 90      | 43      |
+---------------------------+---------+---------+---------+---------+
| ###### Disability stat    |         |         |         |         |
| us {#disability-status-2} |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Persons with            | DNA     | DNA     | DNA     | DNA     |
| > disabilities            |         |         |         |         |
+---------------------------+---------+---------+---------+---------+
| > Persons without         | DNA     | DNA     | DNA     | DNA     |
| > disabilities            |         |         |         |         |
+---------------------------+---------+---------+---------+---------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Illness and disability caused by vaccine-preventable diseases, such as
hepatitis B, measles, and varicella, continue among adolescents.Error:
Reference source not found While primary health care providers are vital
to ensuring that infants and younger children are up to date on their
vaccinations, they have an equally important role in ensuring
comprehensive vaccination for adolescents.[^70] Any new universally
recommended vaccine for adolescents should be at a 90 percent coverage
level within 5 years of the recommendation. An estimated 79 percent of
adolescents and children visit a health care provider annually.[^71]
Providers such as nurses, nurse practitioners, pediatricians, family
physicians, general practitioners, and emergency medicine specialists
deliver most of the primary health care received by adolescents.[^72]
Strategies should specifically target these providers to increase
vaccination among adolescents, especially hard-to-reach and at-risk
adolescents in urban and rural areas.

School entry requirements ensure high vaccination levels. Much of the
experience to date in implementing adolescent vaccination comes from
school-based hepatitis B demonstration projects.[^73] To encourage
school participation in an adolescent vaccination program, a partnership
between schools and local health departments is essential.

Managed care organizations also have an increasingly important role in
the delivery of health care services, including vaccinations, to
adolescents. Measures for assessing immunization recommendations for
adolescents have been incorporated into HEDIS 3.0.Error: Reference
source not found Such standards should greatly assist in implementing
immunization recommendations for adolescents in the managed care
setting.

14-28. Increase hepatitis B vaccine coverage among high-risk groups.

Target and baseline:

+-----------+-----------------------------+--------------+-------------+
| Objective | Increase in Hepatitis B     | 1995\        | 2010\       |
|           | Vaccine\                    | Baseline     | Target      |
|           | Coverage in High-Risk       |              |             |
|           | Groups                      |              |             |
+-----------+-----------------------------+--------------+-------------+
|           |                             | #####        |             |
|           |                             | #### Percent |             |
+-----------+-----------------------------+--------------+-------------+
| **        | Long-term hemodialysis      | 35           | 90          |
| 14-28a.** | patients                    |              |             |
+-----------+-----------------------------+--------------+-------------+
| **        | Men who have sex with men   | 9            | 60          |
| 14-28b.** |                             |              |             |
+-----------+-----------------------------+--------------+-------------+
| **        | Occupationally exposed      | 71           | 98          |
| 14-28c.** | workers                     |              |             |
+-----------+-----------------------------+--------------+-------------+

**Target setting method:** 157 percent improvement for long-term
hemodialysis patients; 567 percent improvement for men who have sex with
men; 38 percent improvement for occupationally exposed workers.

**Data sources:** Young Men's Survey, CDC, NCHSTP; Annual Survey of
Chronic Hemodialysis Centers, CDC, NCID, and HCFA; periodic vaccine
coverage\
surveys, CDC, NCID.

Hepatitis B vaccination has been recommended for persons with risk
factors for hepatitis B virus infection since the vaccine was first
licensed in 1981. These risk groups include the following: hemodialysis
patients, men who have sex with men, incarcerated persons, health care
and public safety workers who have exposure to blood in the workplace,
persons with a history of sexually transmitted diseases or multiple sex
partners, injection drug users, and household and sex contacts of
HBV‑infected persons. While data currently are not collected for inmates
in long-term correctional facilities, it is recommended that prison
officials should consider undertaking screening and vaccination programs
directed at inmates with histories of high-risk behaviors.

14-29. Increase the proportion of adults who are vaccinated\
annually against influenza and ever vaccinated against pneumococcal
disease.

Target and baseline:

+---------+-----------------------------+--------------+--------------+
| Ob      | Increase in Adults          | 1998\*\      | 2010\        |
| jective | Vaccinated                  | Baseline\    | Target       |
|         |                             | (unless      |              |
|         |                             | noted)       |              |
+---------+-----------------------------+--------------+--------------+
|         |                             | #####        |              |
|         |                             | #### Percent |              |
+---------+-----------------------------+--------------+--------------+
|         | **Noninstitutionalized      |              |              |
|         | adults aged 65 years and    |              |              |
|         | older**                     |              |              |
+---------+-----------------------------+--------------+--------------+
| **14    | Influenza vaccine           | 64           | 90           |
| -29a.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+
| **14    | Pneumococcal vaccine        | 46           | 90           |
| -29b.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+
|         | **Noninstitutionalized      |              |              |
|         | high-risk adults aged 18 to |              |              |
|         | 64 years**                  |              |              |
+---------+-----------------------------+--------------+--------------+
| **14    | Influenza vaccine           | 26           | 60           |
| -29c.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+
| **14    | Pneumococcal vaccine        | 13           | 60           |
| -29d.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+
|         | **Institutionalized adults  |              |              |
|         | (persons in long-term or    |              |              |
|         | nursing homes)^†^**         |              |              |
+---------+-----------------------------+--------------+--------------+
| **14    | Influenza vaccine           | 59 (1997)    | 90           |
| -29e.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+
| **14    | Pneumococcal vaccine        | 25 (1997)    | 90           |
| -29f.** |                             |              |              |
+---------+-----------------------------+--------------+--------------+

\*Age adjusted to the year 2000 standard population.

^†^National Nursing Home Survey estimates include a significant number
of residents who have an unknown vaccination status. See *Tracking
Healthy People 2010* for further discussion of the data issues.

**Target setting method:** Better than the best.

**Data sources:** National Health Interview Survey (NHIS), CDC,
NCHSnoninstitutionalized populations; National Nursing Home Survey
(NNHS), CDC, NCHSinstitutionalized populations.

Note: The table below may continue to the following page.

<table>
<colgroup>
<col style="width: 28%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 0%" />
<col style="width: 11%" />
<col style="width: 1%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 11%" />
</colgroup>
<thead>
<tr class="header">
<th rowspan="4"><strong>Select Age Groups, 1998 (unless
noted)</strong></th>
<th colspan="11"><p
id="annual-influenza-and-one-time-pneumococcal-vaccination"
class="heading">Annual Influenza and One-Time<br />
Pneumococcal Vaccination</p></th>
</tr>
<tr class="odd">
<th colspan="3"><strong>Noninstitutionalized Adults Aged 65 Years and
Older</strong></th>
<th colspan="4"><strong>Noninstitutionalized High-Risk Adults Aged<br />
18 to 64 Years</strong></th>
<th colspan="4"><strong>Institutionalized Adults Aged<br />
18 Years and Older</strong></th>
</tr>
<tr class="header">
<th><strong>14-29a. Influ-<br />
enza</strong></th>
<th colspan="2"><strong>14-29b. Pneu-<br />
mococcal<br />
Disease</strong></th>
<th colspan="2"><strong>14-29c. Influenza</strong></th>
<th colspan="2"><strong>14-29d. Pneu-<br />
mococ-cal<br />
Disease</strong></th>
<th colspan="2"><strong>14-29e. Influenza (1997)</strong></th>
<th colspan="2"><strong>14-29f. Pneumococcal Disease
(1997)</strong></th>
</tr>
<tr class="odd">
<th colspan="11">Percent</th>
</tr>
</thead>
<tbody>
<tr class="odd">
<td><strong>TOTAL</strong></td>
<td colspan="2">64</td>
<td colspan="2">46</td>
<td colspan="2">26</td>
<td colspan="2">13</td>
<td colspan="2">59</td>
<td>25</td>
</tr>
<tr class="even">
<td colspan="12"><strong>Race and ethnicity</strong></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>American Indian/ Alaska Native</p>
</blockquote></td>
<td colspan="2">DSU</td>
<td colspan="2">DSU</td>
<td colspan="2">29</td>
<td colspan="2">25</td>
<td colspan="2">DSU</td>
<td>DSU</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Asian or Pacific<br />
Islander</p>
</blockquote></td>
<td colspan="2">68</td>
<td colspan="2">36</td>
<td colspan="2">30</td>
<td colspan="2">DSU</td>
<td colspan="2">DSU</td>
<td>DSU</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Asian</p>
</blockquote></td>
<td colspan="2">67</td>
<td colspan="2">36</td>
<td colspan="2">31</td>
<td colspan="2">DSU</td>
<td colspan="2">DNC</td>
<td>DNC</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Native Hawaiian and other Pacific Islander</p>
</blockquote></td>
<td colspan="2">DSU</td>
<td colspan="2">DSU</td>
<td colspan="2">DSU</td>
<td colspan="2">DSU</td>
<td colspan="2">DNC</td>
<td>DNC</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Black or African<br />
American</p>
</blockquote></td>
<td colspan="2">46</td>
<td colspan="2">26</td>
<td colspan="2">23</td>
<td colspan="2">14</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="even">
<td><blockquote>
<p>White</p>
</blockquote></td>
<td colspan="2">65</td>
<td colspan="2">48</td>
<td colspan="2">27</td>
<td colspan="2">13</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="odd">
<td colspan="12"></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Hispanic or Latino</p>
</blockquote></td>
<td colspan="2">51</td>
<td colspan="2">23</td>
<td colspan="2">24</td>
<td colspan="2">11</td>
<td colspan="2">61</td>
<td>23</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Not Hispanic or<br />
Latino</p>
</blockquote></td>
<td colspan="2">64</td>
<td colspan="2">47</td>
<td colspan="2">26</td>
<td colspan="2">13</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Black or African American</p>
</blockquote></td>
<td colspan="2">47</td>
<td colspan="2">26</td>
<td colspan="2">23</td>
<td colspan="2">14</td>
<td colspan="2">61</td>
<td>22</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>White</p>
</blockquote></td>
<td colspan="2">66</td>
<td colspan="2">50</td>
<td colspan="2">27</td>
<td colspan="2">13</td>
<td colspan="2">62</td>
<td>24</td>
</tr>
<tr class="even">
<td colspan="12"><strong>Gender</strong></td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Female</p>
</blockquote></td>
<td colspan="2">63</td>
<td colspan="2">46</td>
<td colspan="2">28</td>
<td colspan="2">13</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Male</p>
</blockquote></td>
<td colspan="2">64</td>
<td colspan="2">47</td>
<td colspan="2">24</td>
<td colspan="2">13</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Education level</strong> (age 25 years and
older)</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Less than high school</p>
</blockquote></td>
<td colspan="2">58</td>
<td colspan="2">40</td>
<td colspan="2">24</td>
<td colspan="2">14</td>
<td colspan="2">DNC</td>
<td>DNC</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>High school<br />
graduate</p>
</blockquote></td>
<td colspan="2">66</td>
<td colspan="2">48</td>
<td colspan="2">26</td>
<td colspan="2">14</td>
<td colspan="2">DNC</td>
<td>DNC</td>
</tr>
<tr class="even">
<td><blockquote>
<p>At least some<br />
college</p>
</blockquote></td>
<td colspan="2">67</td>
<td colspan="2">52</td>
<td colspan="2">31</td>
<td colspan="2">14</td>
<td colspan="2">DNC</td>
<td>DNC</td>
</tr>
<tr class="odd">
<td colspan="12"><strong>Disability status</strong> (1997)</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Persons with<br />
disabilities</p>
</blockquote></td>
<td colspan="2">66</td>
<td colspan="2">47</td>
<td colspan="2">28</td>
<td colspan="2">16</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Persons without disabilities</p>
</blockquote></td>
<td colspan="2">62</td>
<td colspan="2">40</td>
<td colspan="2">23</td>
<td colspan="2">9</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="even">
<td colspan="12"><strong>Select populations</strong> (not age
adjusted)</td>
</tr>
<tr class="odd">
<td colspan="12"><blockquote>
<p>Age groups (1997)</p>
</blockquote></td>
</tr>
<tr class="even">
<td><blockquote>
<p>18 to 49 years</p>
</blockquote></td>
<td colspan="2">NA</td>
<td colspan="2">NA</td>
<td colspan="2">20</td>
<td colspan="2">8</td>
<td colspan="2">59</td>
<td>24</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>50 to 64 years</p>
</blockquote></td>
<td colspan="2">NA</td>
<td colspan="2">NA</td>
<td colspan="2">40</td>
<td colspan="2">19</td>
<td colspan="2">62</td>
<td>23</td>
</tr>
<tr class="even">
<td><blockquote>
<p>65 to 74 years</p>
</blockquote></td>
<td colspan="2">61</td>
<td colspan="2">40</td>
<td colspan="2">NA</td>
<td colspan="2">NA</td>
<td colspan="2">62</td>
<td>28</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>75 to 84 years</p>
</blockquote></td>
<td colspan="2">66</td>
<td colspan="2">46</td>
<td colspan="2">NA</td>
<td colspan="2">NA</td>
<td colspan="2">61</td>
<td>26</td>
</tr>
<tr class="even">
<td><blockquote>
<p>85 years and older</p>
</blockquote></td>
<td colspan="2">67</td>
<td colspan="2">42</td>
<td colspan="2">NA</td>
<td colspan="2">NA</td>
<td colspan="2">66</td>
<td>30</td>
</tr>
<tr class="odd">
<td colspan="12"><h6
id="persons-with-high-risk-conditions-not-age-adjusted-1997">Persons
with high-risk conditions (not age adjusted) (1997)</h6></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Persons with<br />
diabetes</p>
</blockquote></td>
<td colspan="2">68</td>
<td colspan="2">44</td>
<td colspan="2">27</td>
<td colspan="2">15</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Persons with heart disease</p>
</blockquote></td>
<td colspan="2">71</td>
<td colspan="2">51</td>
<td colspan="2">25</td>
<td colspan="2">11</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Persons with lung disease</p>
</blockquote></td>
<td colspan="2">73</td>
<td colspan="2">65</td>
<td colspan="2">25</td>
<td colspan="2">13</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Persons with lung disease<br />
(excluding asthma)</p>
</blockquote></td>
<td colspan="2">74</td>
<td colspan="2">66</td>
<td colspan="2">26</td>
<td colspan="2">14</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Persons with<br />
kidney disease</p>
</blockquote></td>
<td colspan="2">71</td>
<td colspan="2">46</td>
<td colspan="2">21</td>
<td colspan="2">13</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="odd">
<td><blockquote>
<p>Persons with liver disease</p>
</blockquote></td>
<td colspan="2">71</td>
<td colspan="2">43</td>
<td colspan="2">26</td>
<td colspan="2">10</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
<tr class="even">
<td><blockquote>
<p>Persons with<br />
cancer</p>
</blockquote></td>
<td colspan="2">71</td>
<td colspan="2">51</td>
<td colspan="2">25</td>
<td colspan="2">10</td>
<td colspan="2">DNA</td>
<td>DNA</td>
</tr>
</tbody>
</table>

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable. NA = Not applicable.

Note: Age adjusted to the year 2000 standard population.

Note: The table above may have continued from the previous page.

Federal initiatives have highlighted the need to focus vaccination
resources on adults.[^74] Vaccination is an effective strategy to reduce
illness and deaths due to pneumococcal disease and influenza. Current
levels of coverage among adults vary widely among age, risk, and racial
and ethnic groups. Any new universally recommended vaccine for adults
should be at a 60 percent coverage level within 5 years of
recommendation. Influenza and pneumococcal vaccines are covered by
Medicare; thus vaccinating greater numbers of adults aged 65 years and
older is feasible. High-risk adults aged 18 to 64 years may not have
insurance coverage for influenza and pneumococcal vaccines.

With the aging of the U.S. population, increasing numbers of adults will
be at risk for these major causes of illness and death. Persons with
high-risk conditions (that is, heart disease, diabetes, and chronic
respiratory disease[^75]**^,^** [^76]) remain at increased risk for
these diseases, as do persons living in institutional settings.

Continuing education of providers and the community is needed to
increase awareness of and demand for adult vaccination services.
Interventions such as standing orders for vaccination, provider
reminders and feedback, and patient notifications and reminders have
been effective in increasing adult vaccination levels.Error: Reference
source not found**^,^** [^77] Guidelines and tools for implementing
these interventions are available through *Put Prevention Into
Practice*, a national campaign to improve delivery of clinical
preventive services.[^78] Measurement and feedback about vaccination
providers' performance in delivering vaccines enhance coverage rates.
Providers should be given feedback on their performance in a timely
manner. Measurement and feedback can result in improvements in vaccine
coverage either by changing provider knowledge, attitudes, and behavior
or by stimulating changes in the vaccine delivery system---for example,
reminders and standing orders---or some combination.

In addition, opportunities for vaccination outside of primary care and
other traditional health care settings could be increased to reach
adults who do not routinely access primary care. For example, over 90
million emergency department visits are made in the United States
annually. Emergency department vaccination is likely to increase
vaccination rates among select populations difficult to vaccinate
through office-based programs. In any nontraditional site, a method for
tracking and communicating vaccinations is needed so that vaccination
information may be shared with patients' primary care providers.[^79]

### Vaccine Safety

14-30. Reduce vaccine-associated adverse events.

**14-30a**. Eliminate vaccine-associated paralytic polio (VAPP).

**Target:** Zero cases.

**Baseline:** 5 VAPP cases occurred in 1997.

**Target setting method:** Total elimination.

**Data source:** National Notifiable Disease Surveillance System
(NNDSS), CDC, EPO.

**14-30b.** Reduce febrile seizures following pertussis vaccines.

**Target:** 75 febrile seizures.

**Baseline:** 152 febrile seizures followed pertussis vaccines in 1998.

**Target setting method:** 50 percent improvement.

**Data sources:** Vaccine Adverse Event Reporting System (VAERS) and
Vaccine Safety Datalink (VSD), CDC, NIP.

Because no natural reservoirs for wild poliomyelitis exist,
vaccine-associated paralytic polio (VAPP) is caused by the oral polio
vaccine (OPV). With global polio eradication targeted for 2000, use of
OPV should decrease and then stop, resulting in zero cases of VAPP. From
1980 to 1998, no indigenous cases of paralytic poliomyelitis caused by
wild polio virus transmission have occurred in the United States.
However, 141 cases of VAPP have been reported in this same period,
averaging 8 or 9 cases per year. Persons with VAPP experience the full
range of illness and disability as well as loss of social function
associated with being partially or fully paralyzed. Due to the progress
in global poliomyelitis eradication and to the reduction of the burden
of VAPP in the United States, ACIP recommended that beginning in 2000,
only intravenous polio vaccine (IPV) will be used for routine
immunization.[^80] In general, IPV is as effective as OPV and should be
sufficient at preventing polio in the United States.

Controlled clinical trials indicate that whole cell pertussis (wP)
vaccines cause seizures at a frequency of 1 per 1,750 doses.Error:
Reference source not found**^,^** [^81]**^,^** [^82] The majority of
these seizures are febrile seizures without any residual deficit.
Nevertheless, such seizures---frightening patients and parents
alike---frequently result in emergency department or other medical
visits as well as costly diagnostic evaluations to rule out possible
neurologic disorders. Recently licensed acellular pertussis (aP)
vaccines are less likely to cause fever or seizures; data show seizure
frequency of up to 1 per 14,280 doses.Error: Reference source not found
With the increasing use of aP vaccines, the number of pertussis
vaccine-associated febrile seizures should be reduced by 50 percent.

14-31. Increase the number of persons under active surveillance for
vaccine safety via large linked databases.

**Target:** 13 million persons.

**Baseline:** 6 million persons were under active surveillance for
vaccine safety via large linked databases in 1999.

**Target setting method:** 117 percent improvement.

**Data source:** Vaccine Safety Datalink, CDC, NIP.

A high standard of safety is expected of vaccines since they are
recommended for millions of healthy people, including infants. Vaccine
safety monitoring to identify and minimize vaccine-related reactions is
necessary to help ensure safety because no vaccine is completely safe.
Knowledge of vaccine safety is essential to assess accurately the risks
and benefits in formulating vaccine use recommendations. For example,
the Institute of Medicine has reported that of 76 adverse events
assessed, 66 percent had inadequate or no evidence available to accept
or reject vaccine as a cause of the adverse reactions.[^83]**^,^** [^84]

In collaboration with several health maintenance organizations, CDC has
linked anonymous vaccination and medical records in a large
database.[^85] This system is used to study vaccine safety, especially
for evaluating new concerns arising from the Vaccine Adverse Event
Reporting System (VAERS) and other sources. These databases also are
used for monitoring vaccine safety, conducting active surveillance of
VPDs, carrying out vaccine safety and immunogenicity trials, evaluating
vaccine economics, and assessing vaccine coverage.

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-1. Persons with health insurance

1-2. Health insurance coverage for clinical preventive services

1-3. Counseling about health behaviors

1-4. Source of ongoing care

1-5. Usual primary care provider

1-6. Difficulties or delays in obtaining needed health care

1-7. Core competencies in health provider training

1-8. Racial and ethnic representation in health professions

1-9. Hospitalization for ambulatory-care-sensitive conditions

1-14. Special needs of children

1-15. Long-term care services

7\. Educational and Community-Based Programs

7-2. School health education

7-4. School nurse-to-student ratio

7-5. Worksite health promotion programs

7-6. Participation in employer-sponsored health promotion activities

7-7. Patient and family education

7-8. Satisfaction with patient education

7-9. Health care organization sponsorship of community health promotion\
activities

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

7-12. Older adult participation in community health promotion activities

8\. Environmental Health

8-5. Safe drinking water

8-6. Waterborne disease outbreaks

8-29. Global burden of disease

8-30. Water quality in the U.S.-Mexico border region

10\. Food Safety

10-1. Foodborne infections

10-2. Outbreaks of foodborne infections

10-3. Antimicrobial resistance of *Salmonella* species

10-5. Consumer food safety practices

10-6. Safe food preparation practices in retail establishments

11\. Health Communication

11-1. Households with Internet access

11-2. Health literacy

11-3. Research and evaluation of communication programs

11-4. Quality of Internet health information sources

11-5. Centers for excellence

11-6. Satisfaction with health care providers' communication skills

13\. HIV

13-9. HIV/AIDS, STD, and TB education in State prisons

13-11. HIV testing in TB patients

13-12. Screening for STDs and immunization for hepatitis B

16\. Maternal, Infant, and Child Health

16-22. Medical homes for children with special health care needs

23\. Public Health Infrastructure

23-1. Public health employee access to the Internet

23-2. Public access to information and surveillance data

23-3. Use of geocoding in health data systems

23-4. Data for all population groups

23-5. Data for Leading Health Indicators, Health Status Indicators, and
Priority Data Needs at State, Tribal, and local levels

23-6. National tracking of Healthy People 2010 objectives

23-7. Timely release of data on objectives

23-8. Competencies for public health workers

23-9. Training in essential public health services

23-10. Continuing education and training by public health agencies

23-11. Performance standards for essential public health services

23-12. Health improvement plans

23-14. Access to epidemiology services

23-15. Model statutes related to essential public health services

23-17. Population-based prevention research

25\. Sexually Transmitted Diseases

25-13. Hepatitis B vaccine services in STD clinics

## Terminology

(A list of abbreviations and acronyms used in this publication appears
in Appendix H.)

**Advisory Committee on Immunization Practices (ACIP):** Federally
chartered advisory committee with the goals of providing advice to the
CDC Director on decreasing disease through the use of vaccines and other
biological products and on improving the safety of their use.

**Colonization:** The establishment of a colony or growth of an organism
in a patient, typically in a nonsterile anatomic site such as the skin,
nasal mucosa, or colon.

**Common cold:** Defined based on International Classification of
Disease (ICD)-9 diagnostic codes 460.0, 461.0, 465.0, 465.8, 465.9, and
472.0.

**Complete curative therapy:** Full course of recommended treatment.

**Comprehensive primary care:** All aspects of routine health care
(preventive, diagnostic, and therapeutic) delivered by a trained health
care provider.

**Conjugate vaccine:** A type of inactivated vaccine composed of
fractions of bacteria linked to a protein. This linkage makes the
vaccine more potent.

**Distant infection:** The spread of infection in a patient from one
anatomic site to another site in the body, such as through the blood
stream from the lungs to the liver or brain.

**Emerging infectious diseases:** Diseases of infectious origin whose
occurrence in humans has increased within the past two decades or
threatens to increase in the near future. Recognition of an emerging
disease occurs because the disease is present in the population for the
first time, the disease has been detected for the first time, or links
between an infectious agent and a chronic disease or syndrome have only
recently been identified.

**Group B *Streptococcus* (GBS):** A normal germ found in the intestines
and on the genitals of about one out of five pregnant women. GBS is
usually not harmful to the woman carrying the germ but it can cause
dangerous infections in the blood, spinal fluid, and lungs of babies
born to these women.

> **Early onset of group B streptococcal disease:** Illness onset at
> less than 7 days of age.
>
> **Invasive group B streptococcal disease:** Isolation of group B
> S*treptococcus* from a normally sterile site, such as blood or
> cerebrospinal fluid.

**Group immunity:** The immunity of a group or community. Immunity based
on the resistance to infection among a high proportion of individual
members of the group.

**Hospital-acquired infection:** Any infection that a patient acquires
as a result of medical treatment while in the hospital.

**Invasive pneumococcal infection:** Isolating the bacteria
*Streptococcus pneumoniae* from a normally sterile site, including
blood, cerebrospinal fluid, or pleural fluid.

**Latent TB infection:** The state of being infected with the organism
*Mycobacterium tuberculosis* but without signs or symptoms of active TB
disease.

**Multiple sex partners:** More than one partner in the prior 6 months.

**National Notifiable Disease Surveillance System (NNDSS):** Tracking
system that State health departments use to report cases of selected
diseases to CDC. (See Reportable disease).

**Patient day:** A day or part of a day for which a patient was
hospitalized.

**Penicillin resistant:** Having a minimum inhibitory concentration
(MIC) equal to or greater than 2 μg/ml. Strains with "intermediate"
susceptibility are not included in this category.

**Reemerging infectious diseases:** Reappearance of a known infection
after a decline in occurrence. Reemergence of "old" infectious agents
can be the result of lapses in public health measures, changes in human
behavior that increase person-to-person transmission of infectious
agents, changes in food handling or eating habits, or changes in the way
humans interact with their environment.

**Reportable disease:** A disease for which there are legal requirements
for reporting and notification to public health authorities. In the
United States, requirements for reporting diseases are mandated by State
laws or regulations, and the list of reportable diseases in each State
differs.

**Surveillance regions:** The nine regions of the United States used for
influenza surveillance purposes.

**Vaccine Adverse Event Reporting System (VAERS).** A passive
surveillance system that monitors vaccine safety by collecting and
analyzing reports of adverse events following immunization from vaccine
manufacturers, private practitioners, State and local public health
clinics, parents, and individuals who receive vaccines. CDC and the Food
and Drug Administration work together to implement VAERS.

**Vaccines:** Biological substances used to stimulate the development of
antibodies and thus confer active immunity against a specific disease or
number of diseases.

**Vector-borne disease:** Viral and bacterial diseases transmitted to
humans by arthropods, primarily mosquitoes, ticks, and fleas.

**Zoonotic disease:** Viral and bacterial diseases transmitted to humans
by arthropods, primarily mosquitoes, ticks, and fleas.

## References

[^1]: Hoyert, D.L.; Kochanek, K.D.; and Murphy, S.L. Deaths: Final data
    for 1997. *National Vital Statistics Reports* 19(47):1999.

[^2]: Meltzer, M.I.; Dennis, D.T.; and Orloski, K.A. The cost
    effectiveness of vaccinating against Lyme disease. *Emerging
    Infectious Diseases* 5(3):321-328, 1999.
    \<http://www.cdc.gov/ncidod/eid/vol5no3/meltzer.htm\>December 14,
    1999.

[^3]: Centers for Disease Control and Prevention (CDC). Summary of
    notifiable diseases---United States, 1994. *Morbidity and Mortality
    Weekly Report* 43(53), 1995.

[^4]: National Communicable Disease Center (NCDC). *Rubella Surveillance
    No. 1*. Atlanta, GA: NCDC, 1969.

[^5]: Atkinson, W.; Wolfe, C.; Humiston, S.G.; et al.; eds.
    *Epidemiology and Prevention of Vaccine-Preventable Diseases*.
    Atlanta, GA: U.S. Department of Health and Human Services (HHS),
    CDC, 2000.

[^6]: Atkinson, W.L.; Orenstein, W.A.; and Krugman, S. The resurgence of
    measles in the United States, 1989--90. *Annual Review of Medicine*
    43:451-463, 1992.

[^7]: Gindler, J.S.; Atkinson, W.L.; Markowitz, L.E.; et al. The
    epidemiology of measles in the United States in 1989--1990.
    *Pediatric Infectious Disease Journal* 11(10):841-846, 1992.

[^8]: National Vaccine Advisory Committee. The measles epidemic: The
    problems, barriers and recommendations. *Journal of the American
    Medical Association* 266(11):1547-1552, 1991.

[^9]: Ekwueme, D.U.; et. al. Economic evaluation of use of diphtheria,
    tetanus, and acellular pertussis vaccine (DTaP) or diphtheria,
    tetanus and whole-cell pertussis vaccine (DTwP) in the United
    States, 1997. *Archives of Pediatric and Adolescent Medicine*. (in
    press) August 2000.

[^10]: CDC. Achievements in public health, 1900--1999: Impact of
    vaccines universally recommended for children---United States,
    1990--1998. *Morbidity and Mortality Weekly Report* 48(12):243-248,
    1999.

[^11]: CDC. Notice to readers: National vaccination coverage levels
    among children aged 19--35 months---United States, 1998. *Morbidity
    and Mortality Weekly Report* 48(37):829-830, 1999.

[^12]: National Center for Health Statistics (NHCS). *Healthy People
    2000 Review, 1998--99.* Hyattsville, MD: Public Health Service
    (PHS), 1999, 195-205.

[^13]: CDC. Vaccination coverage by race/ethnicity and poverty level
    among children aged 19--35 months---United States, 1996. *Morbidity
    and Mortality Weekly Report* 46(41):963-968, 1997.

[^14]: CDC. *State Immunization Requirements, 1998--1999.* Washington,
    DC: U.S. Government Printing Office, 1999, 1-27.

[^15]: CDC. Prevention of hepatitis A through active or passive
    immunization: Recommendations of the Advisory Committee on
    Immunization Practices (ACIP). *Morbidity and Mortality Weekly
    Report* 48(RR-12):1-37, 1999.

[^16]: CDC, NCHS. National Health Interview Survey, unpublished data.

[^17]: CDC. Progress toward elimination of *Haemophilus influenzae* type
    b disease among infants and children---United States, 1987--1995.
    *Morbidity and Mortality Weekly Report* 45(42):901-906, 1996.

[^18]: Schuchat, A.; Robinson, A.K.; and Wenger, J.D. Bacterial
    meningitis in the United States in 1995. *New England Journal of
    Medicine* 337:970-976,1997.

[^19]: CDC. *Preventing Emerging Infectious Diseases Threat: A Strategy
    for the 21st Century.* Atlanta, GA: HHS, PHS, 1998.
    \<http://www.cdc.gov/ncidod/emergplan\>October 12, 1999.

[^20]: HHS. *Adult Immunization Action Plan, Report of the Workgroup on
    Adult Immunization.* Washington, DC: HHS, 1997.
    \<http://www.cdc.gov/od/nvpo/adult.htm\>November 23, 1999.

[^21]: CDC. Reported vaccine-preventable disease---United States, 1993,
    and the Childhood Immunization Initiative. *Morbidity and Mortality
    Weekly Report* 43(4):57-60, 1994.

[^22]: Shefer, A.; Briss, P.; Rodewald, L.; et al. Improving
    immunization coverage rates: An evidence-based review of the
    literature. *Epidemiologic Reviews* 21(1), 1999.

[^23]: Hoekstra, E.J.; LeBaron, C.W.; Megaloeconomou, Y.; et al. Impact
    of a large-scale immunization initiative in the Special Supplemental
    Nutrition Program for Women, Infants, and Children (WIC). *Journal
    of the American Medical Association* 280(13):1143-1147, 1998.

[^24]: Abramson, J.S.; O'Shea, T.M.; Ratledge, D.L.; et al. Development
    of a vaccine tracking system to improve the rate of age-appropriate
    primary immunization in children of lower socioeconomic status.
    *Journal of Pediatrics* 126(4):583-586, 1995.

[^25]: CDC. Progress toward eliminating *Haemophilus influenzae* type b
    disease among infants and children---United States, 1987--1997.
    *Morbidity and Mortality Weekly Report* 47(46):993-998,1998.

[^26]: CDC. Summary of notifiable diseases---United States 1997.
    *Morbidity and Mortality Weekly Report* 46(54):1-87, 1998.

[^27]: CDC. Prevention of varicella: Recommendations of the Advisory
    Committee on Immunization Practices (ACIP). *Morbidity and Mortality
    Weekly Report* 45(RR-11):1‑25, 1996.

[^28]: CDC. National, State and urban area vaccination coverage levels
    among children aged 19--35 months---United States, 1997. *Morbidity
    and Mortality Weekly Report* 47(26):547-554, 1998.

[^29]: Rota, J.S.; Heath, J.L.; Rota, R.A.; et al. Molecular
    epidemiology of measles virus: Identification of pathways of
    transmission and implications for measles elimination. *Journal of
    Infectious Diseases* 173(1):32-37, 1996.

[^30]: CDC. Measles---United States, 1996, and the interruption of
    indigenous transmission. *Morbidity and Mortality Weekly Report*
    46(11):242-246, 1997.

[^31]: CDC. Epidemiology of measles---United States, 1998. *Morbidity
    and Mortality Weekly Report* 48(34):749-753, 1999.

[^32]: Wharton, M. Mumps. In: Wallace, R.B.; Duebbeling, B.N.; Last,
    J.M.; et al.; eds. *Public Health and Preventive Medicine*. 14th ed.
    Stamford, CT: Appleton & Lange, 1998, 93-95.

[^33]: CDC. Measles, mumps and rubella---vaccine use and strategies for
    elimination of measles, rubella---and congenital rubella syndrome
    and control of mumps: Recommendations of the Advisory Committee on
    Immunization Practices (ACIP). *Morbidity and Mortality Weekly
    Report* 47(RR-8):1-57, 1998.

[^34]: CDC. Rubella and congenital rubella syndrome---United States,
    1994--1997. *Morbidity and Mortality Weekly Report* 46(16):350-354,
    1997.

[^35]: Bisgard, K.M.; Hardy, I.R.B.; Popovic, T.; et al. Respiratory
    diphtheria in the United States, 1980--1995. *American Journal of
    Public Health* 88(5):787-791, 1998.

[^36]: CDC. Toxigenic *Corynebacterium diphtheriae---*Northern Plains
    Indian Community, August--October 1996. *Morbidity and Mortality
    Weekly Report* 46(22):506-510, 1997.

[^37]: Bardenheier, B.; Prevots, D.R.; Khetsuriani, N.; et al. Tetanus
    surveillance---United States, 1995--1997. *Morbidity and Mortality
    Weekly Report* 47(SS-2):1-13, 1998.

[^38]: CDC. Pertussis vaccination: Use of acellular pertussis vaccines
    among infants and young children. *Morbidity and Mortality Weekly
    Report* 46(RR-7):1-25, 1997.

[^39]: Guris, D.; Strebel, P.M.; Tachdjian, R.; et al. Effectiveness of
    the pertussis vaccination program as determined by use of the
    screening method---United States, 1992--1994. *Journal of Infectious
    Diseases* 176(2):456-463, 1997.

[^40]: Bisgard, K.M.; Kao, A.; Leake, J.; et al. The epidemiology of
    *Haemophilus influenzae* invasive disease in the United States,
    1994--1995: Near disappearance of vaccine-preventable childhood
    disease. *Emerging Infectious Diseases* 4(2):229-237, 1998.

[^41]: CDC. Varicella-related deaths among adults---United States, 1997.
    *Morbidity and Mortality Weekly Report* 46(19):409-412, 1997.

[^42]: CDC. *Hepatitis Surveillance Report.* No. 56. Atlanta, GA: CDC,
    1996.

[^43]: CDC. Hepatitis B virus: A comprehensive strategy for eliminating
    transmission in the United States through universal childhood
    vaccination: Recommendations of the Advisory Committee on
    Immunization Practices (ACIP). *Morbidity and Mortality Weekly
    Report* 40(RR-13):1-19, 1991.

[^44]: CDC. Recommendations for prevention and control of hepatitis C
    virus (HCV) infection and HCV-related chronic disease. *Morbidity
    and Mortality Weekly Report* 47(RR-19):1-39, 1998.

[^45]: CDC. A strategic plan for the elimination of tuberculosis in the
    United States. *Morbidity and Mortality Weekly Report* 38(S-3):1-25,
    1989.

[^46]: American Thoracic Society and CDC. Treatment of tuberculosis and
    tuberculosis infection in adults and children. *American Journal of
    Respiratory Care Medicine* 149:1359-1374, 1994.

[^47]: CDC. Screening for tuberculosis and tuberculosis infection in
    high-risk populations. *Morbidity and Mortality Weekly Report*
    44(RR-11):9-13, 1995.

[^48]: Marshall, B., and Warren, J.R. Unidentified curved bacilli on
    gastric epithelium in active chronic gastritis. *Lancet*
    1:1273-1275, 1983.

[^49]: CDC. Knowledge about causes of peptic ulcer disease---United
    States. *Morbidity and Mortality Weekly Report* 45(42):985-987,
    1997.

[^50]: American Digestive Health Foundation and Opinion Research
    Corporation. *Familiarity With H. pylori Among Adults With Digestive
    Disorders and Their Views Toward Diagnostic and Treatment Options*.
    Bethesda, MD: the Foundation and the Corporation, 1995.

[^51]: Breuer, T.; Malaty, H.M.; Goodman, K.; et al. Has the scientific
    evidence about *Helicobacter pylori* infection in gastrointestinal
    diseases reached the practicing physicians in the U.S.? *American
    Journal of Gastroenterology* 91:1905, 1996.

[^52]: CDC. National Center for Infectious Diseases, Division of
    Bacterial and Mycotic Diseases, Atlanta, GA, 1999.

[^53]: Powell, S.E.; Marcy, S.M.; Phillips, W.R.; et al. Otitis
    media---principles of judicious use of antimicrobial agents.
    *Pediatrics* 101:165-171, 1998.

[^54]: Institute of Medicine (IOM). *To Err Is Human: Building a Safer
    Health System*. Kohn, L.T.; Corrigan, J.M.; and Donaldson, M.S.;
    eds. Washington, DC: Committee on Quality of Health Care in America,
    IOM, 2000.

[^55]: Redd, S.C.; Markowitz, L.E.; and Katz, S.L. Measles Vaccine. In:
    Plotkin, S.A., and Orenstein, W.A., eds. *Vaccines*. 3rd ed.
    Philadelphia, PA: W.B. Saunders Company, 1999, 222-226.

[^56]: Orenstein, W.H.; Hinman, A.R.; and Rodewald, L.E. Public health
    considerations in the United States. In: Plotkin, S.A., and
    Orenstein, W.A., eds. *Vaccines*. 3rd ed. Philadelphia, PA: W.B.
    Saunders Company, 1999, 1006-1032.

[^57]: Dowdle, W.R., and Hopkins, D.R., eds. *The Eradication of
    Infectious Diseases: Dahlem Workshop Report*. Chichester, NY: John
    Wiley and Sons, 1997, 1-218.

[^58]: CDC. School immunization requirements for measles---United
    States, 1981. *Morbidity and Mortality Weekly Report* 30:158-160,
    1981.

[^59]: CDC. Notice to readers: Recommended childhood immunization
    schedule---United States, 2000. *Morbidity and Mortality Weekly
    Report* 49(2):35-38, 47, 2000.

[^60]: CDC, National Immunization Program, Immunization Services
    Division. *Annual Immunization Assessment Progress---Percentage of
    Sites Assessed Nationwide in 1997* \[chart\]. Atlanta, GA: CDC,
    1997. \<http://www.cdc.gov/nip/afix/pres/prog/97perc.gif\>\
    November 23, 1999.

[^61]: Watt, J.; Kahane, S.; Smith, N.; et al. The difference between
    measured and estimated vaccination coverage among private physicians
    in California. Paper presented at Ambulatory Pediatric Association
    in New Orleans, LA, May 1998.

[^62]: LeBaron, C.W.; Chaney, M.; Baughman, A.L.; et al. Impact of
    measurement and feedback on vaccination coverage in public clinics,
    1988--1994. *Journal of the American Medical Association*
    277(8):631-635, 1997.

[^63]: Dini, E.F.; Chaney, M.; Moolenaar, R.L.; et al. Information as
    intervention: How Georgia used vaccination coverage data to double
    public sector vaccination coverage in seven years. *Journal of
    Public Health Management and Practice* 2(1):45-49, 1996.

[^64]: National Committee for Quality Assurance (NCQA). The Health Plan
    Employer Data and Information Set (HEDIS) 3.0/1998, Vol. 2,
    Technical Specifications. Washington, DC: NCQA, 1997, 38-48.

[^65]: CDC. Recommendations of the Advisory Committee on Immunization
    Practices. Programmatic strategies to increase vaccination
    rates---assessment and feedback of provider-based vaccination
    coverage information. *Morbidity and Mortality Weekly Report*
    45(10):219-220, 1996.

[^66]: CDC. *Standards for Pediatric Immunization Practices*.
    Washington, DC: U.S. Government Printing Office, 1993.

[^67]: Briss, P.A.; et al. Reviews of evidence regarding interventions
    to improve vaccination coverage in children, adolescents, and
    adults. *American Journal of Preventive Medicine* 18(1s):97-140,
    2000.

[^68]: CDC. Progress in the development of immunization
    registries---United States, 1999. *Morbidity and Mortality Weekly
    Report* 49(13):274-278, 2000.

[^69]: Sharp, K.; Edgar, T.; and Fowler, K. *Findings of Focus Group
    Research on Immunization Registries.* Rockville, MD: Westat, 1998.
    \<http://www.cdc.gov/nip/registry\
    /i_fgmenu.htm\>October 1999.

[^70]: CDC. Immunization of adolescents: Recommendations of the Advisory
    Committee on Immunization Practices, the American Academy of
    Pediatrics, the American Academy of Family Physicians, and the
    American Medical Association. *Morbidity and Mortality Weekly
    Report* 45(RR-13):1-16, 1996.

[^71]: Benson, V., and Marano, M.A. Current estimates from the National
    Health Interview Survey, 1995. NCHS. *Vital and Health Statistics*
    10(199), 1998.

[^72]: NCHS. *Health*---*United States, 1994.* Hyattsville, MD: PHS,
    1995.

[^73]: Unti, L., and Woodruff, B.A. A review of adolescent school-based
    hepatitis B vaccination projects: A report prepared for the Centers
    for Disease Control and Prevention, Hepatitis Branch. Washington,
    DC: HHS, PHS, October 1996.

[^74]: Fedson, D.S. Adult immunization: Summary of the National Vaccine
    Advisory Committee report. *Journal of the American Medical
    Association* 272(14):1133-1137, 1994.

[^75]: CDC. Prevention and control of influenza: Recommendations of the
    Advisory Committee on Immunization Practices. *Morbidity and
    Mortality Weekly Report* 47(RR-6):1-26, 1998.

[^76]: CDC. Prevention of pneumococcal disease: Recommendations of the
    Advisory Committee on Immunization Practices. *Morbidity and
    Mortality Weekly Report* 46(RR-8):1-24, 1997.

[^77]: Gyorkos, T.W.; Tannenbaum, T.N.; Abrahamowicz, M.; et al.
    Evaluation of the effectiveness of immunization delivery methods.
    *Canadian Journal of Public Health* 85:S14-S30, 1994.

[^78]: HHS. Implementing preventive care. In: *The Clinician's Handbook
    of Preventive Services*. 2nd ed. Washington, DC: HHS, PHS, Office of
    Public Health and Science, Office of Disease Prevention and Health
    Promotion, 1998.

[^79]: CDC. Adult immunization programs in nontraditional settings:
    Quality standards and guidance for program evaluation. *Morbidity
    and Mortality Weekly Report* 49(RR-01):1-13, 2000.

[^80]: CDC. Notice to Readers: Recommendations of the Advisory Committee
    on Immunization Practices: Revised recommendations for routine
    poliomyelitis vaccination. *Morbidity and Mortality Weekly Report*
    48(27):590, 1999.

[^81]: Cody, C.L.; Baraff, L.J.; Cherry, J.D.; et al. Nature and rates
    of adverse reactions associated with DTP and DT immunizations in
    infants and children. *Pediatrics* 68:650-660, 1981.

[^82]: CDC. Diphtheria, tetanus, and pertussis: Recommendations for
    vaccine use and other preventive measures. Recommendations of the
    Advisory Committee on Immunization Practices. *Morbidity and
    Mortality Weekly Report* 40(RR-10):1-28, 1991.

[^83]: Stratton, K.R.; Howe, C.J.; and Johnston, Jr., R.B. *Adverse
    Events Associated with Childhood Vaccines*---*Evidence Bearing on
    Causality.* Washington, DC: National Academy Press, 1994.

[^84]: Howson, C.P.; Howe, C.J.; and Fineberg, F.V. *Adverse Effects of
    Pertussis and Rubella Vaccines.* Washington, DC: National Academy
    Press, 1991.

[^85]: Chen, R.T.; Glasser, J.W.; Rhodes, P.H.; et al. The Vaccine
    Safety Datalink Project: A new tool for improving vaccine safety
    monitoring in the United States. *Pediatrics* 99:765-773, 1997.