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Update Healthy New Jersey 2000
Second Update and Review

Priority Area 8
Prevent And Control Vaccine-Preventable
And Other Infectious Diseases

Introduction

Control of communicable infectious diseases remains a fundamental part of public health programs throughout the world. Although noninfectious diseases have gained increasing prominence and attention, infectious diseases remain a significant potential threat to the health of New Jersey citizens. For diseases for which vaccines are available, immunization is the most cost-effective method of controlling these diseases through prevention. For other diseases, like tuberculosis (TB), efforts are concentrated on identification and effective treatment of infected individuals, to reduce the risk of the disease being spread. The Department has made great progress in immunization of young children, and in recent years has also made immunizing seniors against influenza and pneumonia a priority. The outlook for attaining the year 2000 objectives is mixed, however.

Outlook for Reaching Specific Objectives:
  Achieve target: Likely Unlikely Uncertain
8A. Reduction in measles incidence
X
   
8B. Increase in immunization for measles    
X
8C. Increase in immunization for H. Influenza b
X
   
8D. Surface-antigen-positive women    
X
8E. Reduction in tuberculosis rate for:      
    total population  
X
 
    minorities  
X
 
8F. Reduction in Lyme disease cases  
X
 

Data Update

8A. Decrease the annual incidence of measles (rubeola) by the year 2000 to:

0 cases

Achieve target:LikelyUnlikelyUncertain
X

Incidence Of Measles
Year Total
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
30
911
39
405
462
473
1,138
42
12
175
8
3

After experiencing major outbreaks of measles (rubeola) in 1986 and 1991, the incidence of the disease has decreased greatly. Though the number of cases rose in 1994 as a result of a college outbreak, it quickly returned to a very low level in 1995 and remained there in 1996. The Department will continue active surveillance and rigorous immunization efforts to reach the objective of being measles-free by the year 2000. It appears likely the objective will be achieved by the year 2000.

8B. Increase immunization levels for measles (rubeola) in children by age two to:

90.0 percent

Achieve target:LikelyUnlikelyUncertain


X

Percent Of First Grade Students
Year Percent
1992
1993
1994
1995
1996
1997
64.5
72.4
82.4
81.1
83.6
83.9

Based on the Retrospective School Immunization Survey, immunization levels for measles (rubeola) in children by age two increased by 30 percent from 64.5 percent in 1992 to 83.9 percent in 1997. Information gathered retrospectively on six-year-olds between 1992 and 1997 reflects the immunization status of two-year-old children in 1988 through 1993. The first year these data were available was 1992. It is uncertain whether the objective of 90 percent coverage of children by age two can be achieved by the year 2000, since the rate of increase declined after 1994 and immunization levels have remained fairly steady since then.

8C. Increase immunization levels for H. Influenzae type b started under age one in publicly funded clinics to:

98.0 percent

Achieve target:LikelyUnlikelyUncertain
X

Percent Of Infants
Year Percent
1993
1994
1995
1996
1997
96
97
100
100
97

H. Influenzae type b (Hib) is a disease, most common among children less than five years old, which can cause meningitis and other serious complications. Because it was not possible to account for Hib vaccinations given in the private sector, this objective was revised in 1996 to apply to infants under one year for whom data are now collected in publicly-funded clinics. The 1993 baseline measure for this group of infants was 96 percent. By 1995, the data indicated that all children seen in publicly-funded clinics were immunized for Hib. In 1997, the percentage of immunized children dropped to 97 percent. It remains likely, however, that the year 2000 objective of immunization of 98 percent of infants in publicly-funded clinics will be attained.

8D. Increase immunization levels for hepatitis-B in infants of surface-antigen-positive women treated in publicly-funded clinics by year 2000 to:

90.0 percent

Achieve target:LikelyUnlikelyUncertain


X

Percent Of Infants
 
Year Percent
1994
1995
1996
1997
75
40
74
78

By 1995, a statewide public sector perinatal Hepatitis B Prevention Program had been implemented in all 21 New Jersey counties. All pregnant women receiving care in these agencies are being screened for hepatitis B and, if affected, tracked throughout the perinatal period. By 1997, more than 165 surface antigen positive pregnant women had been identified and were being tracked until delivery. After delivery, their infants were tracked. However, the percentage of infants immunized by eight months of age is not increasing very rapidly, and active maintenance of this program would be needed to assure that this objective is met.

More recently, it has become standard medical practice to recommend immunization of all newborns against hepatitis B. Data is not yet available on how many infants are being immunized statewide.

8E. Decrease the annual incidence of active tuberculosis per 100,000 population to:

4.4 for the total population
13.5 for minorities

Achieve target:LikelyUnlikelyUncertain
total population
X
minorities
X

Incidence Rates Of Tuberculosis
Year Total Minorities
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
9.5
9.7
10.3
12.3
12.5
12.7
12.6
11.6
10.8
10.7
10.3
31.5
33.4
35.5
40.8
41.8
42.3
42.6
36.7
35.9
34.5
31.7

The incidence rate of active tuberculosis (TB) in the total population increased steadily from 1986 through 1991, and then began a steady decline through 1996. The same is true for minorities; the peak came in 1992 for that population. The rates for each group, however, have not gone below their original 1986 levels. During the entire ten year period, the incidence rate of TB for the minority population has been more than three times that of the total population. It is unlikely that either year 2000 TB objective will be achieved.

8F. Decrease the annual incidence of Lyme Disease (with rash) by the year 2000 to:

275 cases per year

Achieve target:LikelyUnlikelyUncertain

X

Annual Incidence Of Lyme Disease (With Rash)
Year Percent
1988
1989
1990
1991
1992
1993
1994
1995
1996
550
680
707
745
559
656
1,306
1,447
1,719

Since 1988, the annual incidence of Lyme disease (with rash) has increased over 200 percent. The number of cases has consistently far exceeded the year 2000 objective. This has occurred despite significant prevention education and tick control efforts throughout the state. It is doubtful that the year 2000 objective will be reached.

Discussion

Vaccines are by far the most effective and inexpensive methods for the prevention and control of communicable diseases. Vaccines against such diseases as measles, poliomyelitis, diphtheria, and pertussis were accepted without question as safe and cost effective when epidemics of these diseases were rampant. Today, measles, poliomyelitis, diphtheria, and pertussis have been brought under control in the United States by improved social and environmental conditions and through systematic use of effective vaccines. The infrequent occurrence of these diseases has caused many individuals to question the need to continue to use these vaccines. However, these diseases have not been eradicated from the world and the use of these vaccines cannot be relaxed without risking the return of epidemics of these diseases.

New Jersey remains vulnerable to epidemics of infectious disease and this vulnerability has particularly negative implications for the young. For the period 1986 through 1993, New Jersey ranked fifth highest in the nation in the number of measles cases occurring per 100,000 population. By 1996, however, New Jersey attained the highest immunization coverage levels and the fewest number of measles cases in its history, but further progress must be made in order to achieve the year 2000 objectives. Improving initial immunization levels among unvaccinated preschool children, historically the most vulnerable and problematic population in New Jersey for this disease, is crucial to reaching the goal.

A number of cooperative public/private efforts have been launched to screen preschool-aged children for their immunization status, directly immunize them or refer them for immunization as needed, and track the ongoing immunization status of children least likely to be protected. Additional federal, state, and private resources have been directed toward these efforts. One of the most ambitious and promising initiatives underway is the development of an electronic immunization registry that not only tracks immunizations, but also facilitates reminders to parents of children who are overdue for particular immunizations and allows providers to assess their own record in immunizing children in their practices. Beginning in 1995, this system has been piloted in Camden, where it has already had a major impact in raising immunization rates.

Beginning in 1997, the Department has issued annual performance reports for commercial managed care plans in New Jersey, including a measure of their success in providing all age- appropriate immunizations to enrolled children two years of age and under. In the November, 1998 performance report, an average of 67 percent of young children enrolled in New Jersey HMOs were fully immunized. However, one HMO achieved an 83 percent rating. The Commissioner issued a challenge to all HMOs to achieve, for all preventive health measures, a target five points higher than the best performer's 1998 record by the year 2000 performance report. For immunization, the target would be 88 percent. HMOs are being required to submit action plans to indicate how they plan to achieve these targets. Their efforts should bring the state as a whole considerably closer to its year 2000 targets.

Other immunization initiatives are also underway. In the greater Newark area, where immunization levels are lower than the statewide averages for New Jersey children, the Department is participating in Partnership to Immunize Newark Kids, a public-private program of comprehensive education, outreach and assessment for both parents and health care providers that will also expand use of the electronic immunization registry.

Special collaborations with the other programs that target areas of need throughout the state, such as the Supplemental Food Program for Women, Infants, and Children (WIC), and Federally Qualified Health Centers, have helped to ensure that increasing numbers of preschool-aged children are vaccinated on time. Also, the increased enrollment of individuals and families in managed care health benefit plans emphasizing preventive services and the implementation of the immunization insurance coverage law to reduce cost barriers should positively influence the immunization of all children from infancy to age 18.

Although the number of people with active tuberculosis in New Jersey is at its lowest point since 1992, TB remains a serious public health problem. Between 1986 and 1992, the incidence of active TB increased 36 percent. After peaking in 1992, active TB cases statewide have declined each year for the past four years. There were 820 cases in 1996, down three percent from the year before and 17 percent since 1992. The occurrence of active TB among children, the emergence of multi-drug resistant strains of TB and the greater incidence of TB among immigrant populations present special challenges in the prevention and control of TB in New Jersey. In addition, minorities continue to be particularly hard hit.

The Department's TB Program provides support to 36 chest clinics throughout the state by providing TB medications free of charge, medical consultation through the National TB Center at The University of Medicine and Dentistry of New Jersey in Newark, nursing/administrative consultation and training to various health professionals. The Department also assists the state and county correctional facilities in both TB surveillance and prevention activities. In addition, federal and state funds are provided via health service grants to selected clinics throughout the state. The focus of support has been to ensure persons that diagnosed with TB or suspected TB complete a recommended course of treatment. These outreach staff provide directly observed therapy (DOT), which has been proven to be effective in reducing the TB morbidity throughout the state as well as the number of cases with multiple drug resistant TB. In 1997, 87 percent of pulmonary active TB cases under chest clinic supervision were placed on DOT. From 1995 through 1997, New Jersey experienced a 15 percent decrease in morbidity (848 to 718 cases). We anticipate these downward trends to continue in 1998.

Prevention of future cases is another major focus of effort. Contact interviewing and investigations are conducted on all reported TB cases and suspected cases with the capability of transmitting their infection to others. Identified individuals are promptly examined and preventive therapy is initiated. In the event of a large scale investigation in a congregate setting, such as a school or workplace, consultation is provided to local programs. Additionally, since individuals with both TB and HIV infection are considered at high risk for progression to active TB, efforts are also made to identify such persons by offering HIV testing and counseling, and to keep them on an appropriate drug regimen with the use of DOT.

The development of antibiotic resistance among microorganisms is a concern not only for tuberculosis, but for many other infectious diseases as well. Microorganisms are developing resistance to antibiotics at an increasing rate. The New Jersey Department of Health has been monitoring the development of antibiotic resistance in New Jersey since 1991, and while the increase in resistance has been small, it is a warning that we cannot become complacent. To maintain control over infectious diseases in the future, it will be necessary to be more judicious in the use of antibiotics and to make better use of disease prevention techniques such as vaccines.

The annual incidence of Lyme disease in New Jersey, a tick-borne illness that was first identified a little over a decade ago, has increased more than 200 percent since 1988. Prevention efforts to date have focused on tick control and personal protection against ticks. However, in 1998 two Lyme disease vaccines were developed and are under review by the Federal Food and Drug Administration. Once these vaccines are widely in use there may be a marked difference in the incidence of Lyme disease.

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