Vaccine History and CDC’s Role in

Monitoring and Responding to Outbreaks of

Vaccine-Preventable Diseases

National Press Foundation

Washington, DC
July 29, 2019
Jay C. Butler, MD
Deputy Director for
Infectious Diseases
Overview
• Control of infectious diseases
• VERY brief history of vaccination
• Public health monitoring of vaccine-preventable
diseases (VPDs)
• Responding to outbreaks of VPDs
3
History of Vaccination--Smallpox
• Variolation
• Inoculating the skin with pus from smallpox lesions
• Indochina circa 1000 CE
• “Milder” illness, subsequent immunity, fatality ~1%
Variolation in America
“In 1736 I lost one of my Sons, a fine Boy of 4
Years old, taken by the Small Pox in the
common way. I long regretted that I had not
given it to him by Inoculation, which I
mention for the Sake of Parents, who omit
that Operation on the Supposition that they
should never forgive themselves if a Child
died under it; my Example showing that the
Regret may be the same either way, and that
therefore the safer should be chosen.”
Benjamin Franklin
1796: Vaccination (vacca, Latin cow)
• Cowpox (vaccinia virus): illness of cattle,
transmissible to humans
• Observed that milkmaids did not acquire
smallpox
• Edward Jenner
• Collected pus from hand of milkmaid
• Inoculated 8-year-old James Phipps
• Developed local lesion and felt unwell for
a few days but fully recovered
• Jenner variolated Phipps—no lesion or
illness
1980: Smallpox eradication
2019: My Father’s Day Present
 Vaccine Preventable Diseases:
Vaccinations Routinely Used in US
• Chickenpox (Varicella)
• Diphtheria
• Hepatitis A
• Hepatitis B
• Haemophilus influenzae type b
• Human papillomavirus
• Influenza
• Measles
• Meningococcus (A/C/W135/Y and B)
• Mumps
• Pneumococcus (13 and 23 valent)
• Pertussis (Whooping Cough)
• Polio
• Rotavirus
• Rubella (German measles)
• Shingles (Herpes Zoster)
• Tetanus
Vaccine Preventable Diseases:
Vaccinations Used for Specific Exposure Risks or
for Travelers
• Adenovirus • Rabies
• Anthrax • Smallpox
• Cholera • Tuberculosis (BCG)
• Ebola • Typhoid Fever
• Japanese Encephalitis • Yellow Fever
Public Health Surveillance/Monitoring
Public Health Surveillance/Monitoring
Public Health Surveillance/Monitoring

“Public health surveillance is

the ongoing systematic
collection, analysis, and
interpretation of data, closely
integrated with the timely
dissemination of these data
to those responsible for
preventing and controlling
disease and injury”

Steve Thacker and Ruth Berkelman

Epidemiologic Rev 1988;10:164-90
Public Health Surveillance/Monitoring
Vaccine-Preventable Diseases
• Track disease rates and trends
• Detect and characterize outbreaks
• Assess burden of disease
• Evaluation interventions and prevention strategies
• Determine optimal vaccine components
• Detect emergence of new diseases
• Monitor vaccine uptake and acceptance
 Laboratory Confirmed Influenza-Associated Hospitalizations

Hospitalizations by Age Overall Hospitalization Rate by Season

250

120

200 100

80

150 60

40

100
20

0
50 40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

0
40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 2009-10 2010-11 2011-12 2012-13 2013-14
0-4yr 5-17yr 18-49yr 50-64yr 65+ yr overall 2014-15 2015-16 2016-17 2017-18 2018-19
Influenza-Associated Mortality
Influenza Positive Tests Reported to CDC by U.S. Public
Health Laboratories, 2018-19 Season
2000

1800

1600

1400

1200

1000

800

600

400

200

0
40 41 42 43 44 45 46 47 48 49 50 51 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
A (Subtyping not Performed) A (2009 H1N1) A (H3) B
US Flu VE* Network sites and principal investigators,
Ambulatory patients—all ages
Kaiser Permanente Washington Marshfield Clinic Research Institute
Mike Jackson Ed Belongia
Lisa Jackson Huong McLean University of Michigan
Arnold Monto
Emily Martin

University of Pittsburgh
Rick Zimmerman
Tricia Nowalk

Baylor Scott and White Health

Manju Gaglani

*US Flu VE--US Influenza Vaccine Effectiveness Network

 Adjusted vaccine effectiveness* against medically attended
influenza by virus subtype, US Flu VE Network, 2018–19
100

80
Adjusted Vaccine Effectiveness (%)

60 44 (36, 51)

40
29 (21, 35) 44

29
9 (-4, 20)
20

9
0
Any influenza A(H1N1)pdm09 A(H3N2)

-20

Influenza (sub)type

* Multivariable logistic regression models adjusted for site, age, sex, race/ethnicity, self-rated general health status, interval from onset to enrollment, and
calendar time.
 WHO Global Influenza Surveillance and Response
System Supported by CDC

 144 National Influenza

Centers in 114 Member
States
 6 Collaborating Centers
for Influenza
 12 A(H5N1) Reference
Labs
Vaccine Virus Selection for 2019-20
 WHO and FDA Vaccines and Related Biological Products Committee
Recommended Composition of Influenza Virus Vaccines for Use in the
2019-2020 Northern Hemisphere Influenza Season:
• A/Brisbane/02/2018 (H1N1)pdm09-like virus
• A/Kansas/14/2017 (H3N2)-like virus (3C.3a)
• B/Colorado/06/2017-like virus (B/Victoria/2/87 lineage)
• B/Phuket/3073/2013-like virus (B/Yamagata/16/88 lineage) –
quadrivalent only
Methods
Design: Test-negative design
 Comparing odds of laboratory-confirmed influenza among vaccinated vs.
unvaccinated patients
 Vaccination status: receipt of one dose (≥1 dose for children 6m-8 years) of any
2018–19 seasonal flu vaccine at least 14 days prior to illness onset
 Sources: Medical records, immunization registries, and/or self-report (self-report
only for inpatient networks)
Analysis: VE = (1 – adjusted OR) x 100%
 Adjustment for potential confounding variables (i.e. study site, age, calendar
time)
Monitoring: Detecting New Disease
Emergence A(H9N2)
A(H5N6)
2017: 2 (China)
2017: 6 (China) 2018: 4 (China, 1 death)
2018: 5 (China) Overall: 23 (11 deaths)
2019: 2 (China)
Overall: 47 (1 death)

A(H7N4)
2017: 1 (China)
2018: 0
Overall: 1 (0 deaths)

A(H5N1)
2017: 4 (Egypt, Indonesia)
2018: 0
Overall: 860 (455 deaths)
 Monitoring Vaccine Uptake and Coverage

National Immunization National Immunization National Health

Survey Survey--Teen Interview Survey
Schuchat A, et al. Emerg Infect Dis 2018; 24(7):1178-87
 Vaccine Coverage among Children 19-35 Months,
National Immunization Survey, United States, 1994-2017

The Healthy People 2020 target for coverage is 90% for all these vaccines with the exception of rotavirus (80%) and HepA (85%).
Abbreviations: MMR = measles, mumps, and rubella vaccine; DTP/DTaP = diphtheria, tetanus toxoids, and pertussis vaccine / diphtheria, tetanus toxoids, and acellular pertussis vaccine; Hib =
Haemophilus influenzae type b vaccine; FS = full series; HepB = hepatitis B vaccine; PCV = pneumococcal conjugate vaccine; HepA = hepatitis A vaccine
 2017 Vaccine Coverage for ≥1 Dose MMR
(ages 19-35 months)
Coverage (%)

82.5-89.3

89.4-91.3

91.4-92.3

92.4-93.7

93.8-98.3

NA

Source: National Immunization Survey-Child (NIS-Child), 1995 through 2017 available online through CDC ChildVaxView at https://www.cdc.gov/vaccines/imz-
managers/coverage/childvaxview/data-reports/index.html
 Vaccine Coverage: Influenza vaccination coverage among adult
populations ≥18 years, 1996-97 through 2016-17 seasons
80

≥65
70
HCP
60
50-64
50 ≥18

40 18-49 high-risk

18-49 not high-risk

30

20

10

Source: National Health Interview Survey (NHIS), 1997-2017

 Very few US toddlers receive no vaccines at all,
but this group is increasing
2

1.1
Percentage of HP2020 Goal: <1%
1
0 Dose children 0.8 0.8 0.8 0.8 0.8
0.7 0.7
0.6 0.6

0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

*Source: National Immunization Survey, MMWR October 12, 2018, 19-35 months at time of survey
 Outbreaks of VPDs: Measles, US, 1960-2019
* Through
July 20

Strebel PM, Orestein WA. New Engl J Med 2019; 381(4):349-357

 Measles, US, 2019
 1164* cases of measles confirmed in 30 states
 ~5% of cases imported; most common sources: Philippines, Ukraine, and Israel
 Measles outbreaks ongoing:
- New York State, Rockland County
- New York City
- California, Butte County
- Pennsylvania, Allegheny County
- Washington, King County

*Through July 25, 2019

For more information please contact the Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
Visit: www.cdc.gov | Contact CDC at: 1-800-CDC-INFO or www.cdc.gov/info

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.
 Top 25 Counties At Risk for Measles
Outbreaks in 2019
Based on 4 factors:
• International air
travel volume
• Measles incidence
in country of travel
origin
• Number of non-
medical exemptions
• Population

Sarkar S, et al. Lancet Infect Dis 2019; 19(7):684-86

 Widespread Hepatitis A Outbreaks,
March 2017-July 19, 2019
• 22,295 cases
• 13,184 hospitalization
• 216 death
• Risk factors
• Homelessness
• Drug use
• Recent incarceration
• MSM
• Chronic liver disease
Ebola, DRC, 2018-19
 As of July 24, 2019: 2,518 confirmed cases, 1,756 deaths
 Ebola outbreak in conflict zone
 Infected HCWs and nosocomial spread once again important (6% of cases)
 Renewed efforts at community engagement
 Trust building extremely challenging
 Systematic evaluation of multiple new therapeutics
 Vaccines are available
Utilization of Ebola Vaccine: Ring Vaccination

Ebola Case

Contact Case

Contact Contact
 CDC Strategic Priorities

End Eliminate Secure global health

epidemics diseases and ensure domestic
preparedness
Influenza
HIV/AIDS Pandemic contagions
Antibiotic resistance
Hepatitis C Vector-borne diseases
Opioid misuse
Vaccine-preventable diseases Terrorism preparedness
Diabetes

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