State Legislative Conference

1. Centers for Disease Control and Prevention
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
National Center for Immunization and Respiratory Diseases
Centers for Disease Control and Prevention
National Center for Immunization and Respiratory Diseases
Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or extended for use in printing or any use by other CDC CIOs or any external audiences.
November 4, 2017
Shannon Stokley, DrPH
Immunization Services Division
Centers for Disease Control and Prevention

2. Smallpox
Polio
Diphtheria
Pertussis
Tetanus
Measles
1964 (6)
Polio
Diphtheria
Pertussis
Tetanus
Measles
Rubella
Mumps
1985 (7)
Polio
Diphtheria
Pertussis
Tetanus
Measles
Rubella
Mumps
Hib (infant)
HepB
HepA
Varicella
Pneumococcal
Influenza
Meningococcal
Rotavirus
HPV
Polio
Diphtheria
Pertussis
Tetanus
Measles
Rubella
Mumps
Hib (infant)
HepB
Varicella
1995 (10)
2017 (16)
Polio
Diphtheria
Pertussis
Tetanus
Measles
Rubella
Mumps
Hib (infant)
HepB
HepA
Varicella
Pneumococcal
Influenza
Meningococcal
Rotavirus
HPV
Number of Diseases Prevented by Vaccines Included in
the Routine Child/Adolescent Immunization Schedule

3. Comparison of 20th Century Annual Morbidity and Current Morbidity:
Vaccine-Preventable Diseases
Disease
20th Century
Annual Morbidity†
2015
Reported Cases † †
Percent
Decrease
Smallpox 29,005 0 100%
Diphtheria 21,053 0 100%
Measles 530,217 189 > 99%
Mumps 162,344 1,057 99%
Pertussis 200,752 18,166 91%
Polio (paralytic) 16,316 0 100%
Rubella 47,745 5 > 99%
Congenital Rubella Syndrome 152 1 99%
Tetanus 580 25 96%
Haemophilus influenzae 20,000 23* > 99%
† JAMA. 2007;298(18):2155-2163
† † CDC. MMWR January 8, 2016/ 64(52);ND-923 – ND-940. (MMWR 2015 week 52 provisional data)
* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 10 cases of Hib are estimated to
have occurred among the 211 reports of Hi (< 5 years of age) with unknown serotype.

4. CDC estimates that vaccination of children
born between 1994 and 2016:
 Prevent 381 million illnesses
 Prevent 24.5 million hospitalizations
 Help avoid 855,000 early deaths
 Save nearly $360 billion in direct costs and
$1.65 trillion in total society costs
 Every dollar spent in childhood vaccination
ultimately saves $10.10.
Childhood Immunization Provides Big Savings
Vaccines for Children: 23 years of protecting America’s children
Updated March 2017 from previous article: Benefits from Immunization During the Vaccines for Children Program Era – United States, 1994-2013. MMWR. 25 April 2014

5. Vaccine Coverage among Children 19-35 Months, National Immunization
Survey, United States, 1994-2016
0
10
20
30
40
50
60
70
80
90
100
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
PercentVaccinated
Year
MMR (1+)
DTP/DTaP (3+)
Polio (3+)
Hib (3+)
HepB (3+)
Varicella (1+)
PCV (4+)
Rotavirus
HepA (2+)
3+HepB
1+ Varicella
4+ PCV 2+ HepA
Rotavirus
<1% of toddlers had received no vaccines

6. Completion of vaccination series by age, National
Immunization Survey-Kindergarten (Oct, 2013 – Mar, 2014)
Smith et al. Vaccine. 2017;35:5346-5351.

8. 0
10
20
30
40
50
60
70
80
90
100
2011-12 2012-13 2013-14 2014-15 2015-16 2016-17
Percent
Median and Range* of Measles, Mumps, and Rubella Vaccine (MMR) Coverage, and
Exemptions from Any Required Vaccination† among Kindergartners, United States, 2011-
12 to 2016-17 School Years
Median MMR Coverage Median Exemption from Any Required Vaccination
Source: School Vaccination Assessment Program, 2011-12, 2012-13, 2013-14, 2014-15, 2015-16, and 2016-17; Available from:
https://www.cdc.gov/vaccines/vaxview/index.html.
Abbreviations: MMR = measles, mumps, and rubella vaccine.

9. 53.8 54.7
43.1
55.8
86.5
89.9 90.5 88.6
0
20
40
60
80
100
DTaP Poliovirus MMR Varicella
Exempt Not Exempt
Vaccination coverage by exemption status, National
Immunization Survey-Kindergarten (Oct, 2013 – Mar 2014)
Smith et al. Vaccine. 2017;35:5346-5351.
 1.9% requested an exemption
 95.6% of exempt children had received
at least 1 dose of vaccine
 Children with an exemption received
an average of 21.8 vaccine doses
 Children without an exemption received
an average of 28.2 vaccine doses

10.  Represents children who are attending kindergarten but do not have documentation
of being vaccinated or requesting an exemption
 Measles vaccination:
– 90.9% vaccinated
– 1.1% requested an exemption and unvaccinated
– 0.3% provisionally enrolled/grace period and unvaccinated
– 7.7% no documentation of vaccination or exemption
Vaccination coverage gap, National Immunization Survey-
Kindergarten (Oct, 2013 – Mar 2014)
Smith et al. Vaccine. 2017;35:5346-5351.

11. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
D C E B P J U O Q T A F G R K I H N L M S
(Weighted)Percent
State
Estimated Percent of Kindergartners with Documented Vaccination for MMR (MMR UTD),
Exempt from MMR Vaccination (MMR Exempt), or in the Vaccination-Exemption Gap (VEG)
- Selected States, 2016-17 School Year
Vaccinated Exempt No documentation

12. 10 Years of HPV Vaccination
0
10
20
30
40
50
60
70
80
90
100
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
PercentVaccinated
Survey Year
Tdap
MCV4
1 HPV girls
3 HPV girls
1 HPV boys
3 HPV boys
1 HPV girls &
boys
88.0
82.2
65.1
56.0
43.0
31.5
60.4
*Source Walker, et al. MMWR; August 25, 2017 / 66(33);874–882

13. Number of HPV-Attributable Cancers Averted over 100 Years of 9-Valent
HPV Vaccination Program
Estimates calculated using published model (Chesson et al, Hum Vaccin Immunother 2016), with modified coverage assumptions. Coverage levels shown (39.7%, 21.6%, and
80%) refer to coverage among ages 13-17. For females, the annual probability of vaccination in the current coverage scenario was modeled as 20.9% for age 12, 8.9% for ages
13 to 18, and 0.89% for ages 19 to 26. For males, these values were 10.5%, 4.4%, and 0.44% (through age 21), respectively. In the 80% coverage scenario, the annual
probability of vaccination was 73.8% for age 12, 8.9% for ages 13 to 18, and 0.89% for those 19 and older (through age 21 for men and age 26 for women).
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
HPV cancers averted total (excluding herd immunity) HPV cancers averted total
NumberofHPV-attributablecancersaverted
2014 coverage (Females 39.7%, Males 21.6%)
Higher male and female coverage (80%)
709,000
1.23
million
Total US population
1.56
million
1.27
million

14. How do we Communicate with Parents about Vaccines?

15. Examples of How We Use a Risk Communication Approach
 Show empathy--we know parents want to protect
their kids
 Acknowledge both benefits and risks of vaccines
 Cite facts and data whenever possible
 Talk about what we don’t know
 Give concrete action steps

16. Frame the Conversation Positively
Source: Opel et al. Pediatrics 2013; 132:1037
 Observational study included 93 discussions about
vaccines
 74% of providers used a presumptive approach
– “He’s due for three shots today”
 26% used a participatory approach
– “What would you like to do about shots?”
 Bottom line: Presumptive approach had less
parental resistance to immunizations (26% versus
83%)

17. HPV Vaccination: Announcement vs. Conversation
 Will a “conversation” versus an “announcement” of vaccines
recommended on the adolescent platform impact uptake?
Brewer NT, Hall ME, Malo TL, et al. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial.
Pediatrics. 2017;139(1):e20161764

18. Structure of “announcement”
 Child is due for 3 vaccines to be given today:
• mentioning the child’s age;
• announcing the child is due for 3 vaccines
recommended for children this age,
• placing HPV vaccine in the middle of list; and
• Saying they will vaccinate today
Brewer NT, Hall ME, Malo TL, et al. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial.
Pediatrics. 2017;139(1):e20161764

19. 6.4
9.5
11.5
14.9
8.4
11.5
0
2
4
6
8
10
12
14
16
3 months 6 months
PercentagePointChangeinCoverage
Time Post-training
Control Announcement Conversation
“Announcement” improved HPV vaccine acceptance,
compared to “conversation”
Brewer NT, Hall ME, Malo TL, et al. Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial.
Pediatrics. 2017;139(1):e20161764

20. Motivational Interviewing Techniques for Difficult Vaccine
Discussions
Slide courtesy of: Sean O’Leary, MD, MPH, NFID Clinical Vaccinology Course ,Spring 2015
 For patients who are unsure or resistant, a closed-
ended question following a recommendation can lead
to less productive conversations
 Motivational interviewing (MI) is a patient-centered,
guiding communication style for enhancing a person’s
own motivation for change or behavioral activation
 MI includes:
– Open-ended questions
– Affirmations
– Reflection
– Summary

21. Some Parents Need Reassurance
 Many parents simply accept this bundled recommendation
 Some parents may be interested in vaccinating, yet still have questions.
Interpret a question as
they need additional reassurance from YOU,
the clinician they trust with their child’s health care
 Ask parents about their main concern
(be sure you are addressing their real concern)
Unpublished CDC data, 2013.

22. Want to See Experts Answering Questions?
www.vaccinateyourbaby.org/faq

23. #HowIRecommend

24. Provider Resources for Vaccine Conversations with Parents
 Developed with partners AAP and
AAFP
 Based on formative research and
reviewed regularly
 Uses risk communication principles
 Provides information for conversations
on vaccines, vaccine safety, and
vaccine preventable diseases
 Includes supplemental resources for
parents
www.cdc.gov/vaccines/conversations

25. Resources for Parents
www.cdc.gov/vaccines/partners/childhood/multimedia.html

26. Resources for Parents:
If you Choose not to Vaccinate
 For parents who are considering or have
decided to delay or refuse recommended
vaccines
 Discusses:
– Steps to take before or during an outbreak to
help protect their family and community
– The importance of notifying healthcare
professionals that a child is not fully
vaccinated
– Considerations when travelling
 Main message: this is not a risk-free choice

27. For more information, contact CDC
1-800-CDC-INFO (232-4636)
TTY: 1-888-232-6348 www.cdc.gov
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Photographs and images included in this presentation are licensed solely for CDC/NCIRD online and presentation use. No rights are implied or extended for use in printing or
any use by other CDC CIOs or any external audiences.
Thank you!