By Anne R. West, MSN, CPNP
and Mary Kopp MN, RN

This century has seen a dramatic decrease in morbidity and mortality from infectious disease (Table 1). Vaccine for diphtheria was introduced in the early part of the century, and was a hallmark for protecting children as well as adults from death and the devastating effects of infectious disease. Shortly thereafter, pertussis and tetanus toxoid were introduced and diphtheria, tetanus and pertussis become the first combination vaccine (dtp). Polio vaccine became available in the mid-1950s and significantly allayed parental fears that their children would be disabled by the disease. Measles, rubella and mumps vaccine followed in the 1960s.

Although many of these diseases were considered "common" childhood illnesses, complications often resulted in significant morbidity and mortality. Hepatitis B was introduced in 1986 as the first recombinant vaccine to provide long-term protection. It was a major breakthrough in providing protection from liver disease and cancer, which costs many thousands of lives each year (Grossman 1995). Although the first dose of this vaccine is administered to infants prior to leaving the hospital, there are two additional doses that are needed. It is recommended that children not immunized prior to 1992, when Hepatitis B became a part of the Advisory Committee on Immunization Practice (ACIP) schedule, now receive this vaccination. Several states now require Hepatitis B for school entry. It is largely the adolescent population that has not been immunized against Hepatitis B. Efforts are currently underway to develop programs in middle and high schools.

Many providers never see a child with meningitis due to the introduction of haemophilus influenzae type b (Hib) vaccine in 1989. The newest vaccine is varicella (chicken pox), introduced in 1996. This vaccine is now recommended by the ACIP. Concurrent with the writing of this continuing education program, rotovirus vaccine was approved by the Food and Drug Administration (FDA). This vaccine is specific to infant diarrhea. In October, 1999 rotovirus vaccine was voluntarily withdrawn from the list of available vaccines due to a potential association between the available vaccine and intussusception (bowel obstruction). Research is ongoing to verify/dispel that association. Other vaccines are anticipated in the next few years, namely pneumococcus conjugate, which will successfully immunize infants against otitis media. It is also anticipated that some of the current vaccines will be eliminated with the global eradication of certain diseases, such as polio and measles. The Centers for Disease Control and Prevention (CDC) is diligently working with many organizations to eradicate polio worldwide by the year 2000 and possibly eradicate measles worldwide in the next 10 years.

Eighty percent of the recommended vaccines for children should be given before the age of two. This affords protection during the period of time when children are most susceptible to infectious disease. Most children are fully immunized at school age; however, there are no formal legislative mandates indicating that children be immunized by their second birthday, when they are most vulnerable to the devastating effects of vaccine preventable disease.

In 1992, only 55.3% of children under the age of two had received 4 DTaPs, 3 polio and I MMR (4:3:1) (CDC 1997). It was these statistics that initiated President Clinton's Childhood Immunization Initiative (CII). In 1993, the rate rose to 67.1%, and in 1994, it had risen to 72.5%. These rates did not include the Hib vaccine. At this time, we are close to reaching a 90% level; however, there is still a long way to go, with many cities identified by CDC as Pockets of Need (PON) where immunization rates are less than 75%. These cities include: New York City, Los Angeles, Chicago, Houston, Detroit, Philadelphia, San Diego, Dallas, San Antonio, Phoenix and Miami.

The CII identified many initiatives in order to meet the needs of the under-served, undocumented and uninsured children. There has been a significant growth of many partnerships among public and private agencies as well as the development of state and local immunization coalitions. The work of these partnerships has begun to achieve a dramatic increase in immunization rates for children less than two years of age. By their second birthday, children should have received four doses of diphtheria/tetanus/pertussis (DTaP), four doses of Haemophilus influenza type b, three polio (IPV/OPV), three Hepatitis B (HepB), measles/mumps/rubella (MMR) and varicella. DTaP is the preferred vaccine for all doses in the vaccination series because it is more effective than DTaP (89% effective in preventing WHO-defined pertussis when given as a three-dose primary series). The goal is to achieve a 90% vaccination level for all infants by the year 2000. Reaching this goal is only the first step in ensuring that young children in the United States are protected from preventable infectious diseases.

In 1994, the Vaccine for Children (VFC) program provided free vaccines for providers to immunize those children who meet certain economic criteria. The Vaccines for Children (VFC) program is a federally funded program. It supplies vaccine at no cost to public and private health care providers who enroll and agree to immunize eligible children in their medical practice or clinic. The VFC program was created by the Omnibus Budget Reconciliation Act (OBRA) of 1993 and began on October 1, 1994. The VFC program was designed to:

• reduce the cost of vaccines for a physician or medical practice
• create fewer barriers for parents to immunize their children
• save parents about $340 per child in expenses for vaccines
• keep children in their medical home when they qualify for VFC.

Availability of these vaccines allows all children to be immunized in any setting regardless of ability to pay. Any child from birth through 18 years age is eligible to receive VFC supplied vaccine if he/she meets at least one of the following criteria:

• The child does not have health insurance.
• The child is enrolled in Medicaid (including Medicaid HMOs).
• The child is a Native American or Alaskan Native.