Download Vaccine-preventable diseases in upstate New York

T
H
E
F
A
C
T
S
A
B
O
U
T
Vaccine-preventable diseases in upstate New York
Reported cases (rates per 100,000 people) of select
vaccine-preventable diseases* (all ages), 2012
New York State
Total cases:
Influenza cases:
Pertussis cases:
27,342 (139.7)
22,158 (113.2)
3,171 (16.2)
Central New York Region
Total cases:
Influenza cases:
Pertussis cases:
4,236 (392.3)
3,867 (358.1)
258
(23.9)
Upstate New York
Total cases:
Influenza cases:
Pertussis cases:
13,085 (263.7)
11,198 (225.7)
1,321 (26.6)
* Vaccine-preventable diseases include
diphtheria, hepatitis A, hepatitis B, hepatitis B
acute, hepatitis B perinatal, influenza,
measles, meningococcal, mumps, pertussis,
pneumococcal, rubella and tetanus.
Source: New York State Department of
Health. Communicable Disease Annual
Reports. “Reported Cases by Disease and
County – 2012.”
http://www.health.ny.gov/statistics/diseases/
communicable/2012/
Finger Lakes Region
Total cases:
Influenza cases:
Pertussis cases:
2,653 (246.8)
2,235 (208.0)
293 (27.3)
Note: Upstate New York refers to the New
York counties highlighted on this map.
Utica/Rome/North Country Region
Total cases:
Influenza cases:
Pertussis cases:
Western New York Region
Total cases:
Influenza cases:
Pertussis cases:
1,615 (104.9)
1,101 (71.5)
349 (22.7)
2,940 (386.1)
2,663 (349.7)
181 (23.8)
Southern Tier Region
Total cases:
Influenza cases:
Pertussis cases:
1,641 (325.0)
1,332 (263.8)
240 (47.5)
Although the rates of most vaccine-preventable illnesses in the U.S. have reached historic lows, a small
percentage of Americans forgoes immunizations, thereby raising the public health threat of avoidable disease outbreaks.1 According to the Centers for Disease Control and Prevention, widespread
vaccination has eradicated smallpox and made the occurrence of diseases such as polio and diphtheria
exceedingly rare, but outbreaks of other diseases continue to pose risks.2
The true burden of vaccine-preventable diseases is undercounted, because many cases go
undiagnosed, and some diseases, such as varicella (chicken pox), are not reported in New York state.
The incidence of most of the 13 vaccine-preventable diseases included in this report was low in
upstate New York and New York state in 2012, compared to the pre-vaccine era. An uptick in influenza in upstate New York brought the overall incidence of vaccine-preventable illnesses in upstate
New York (263.7 per 100,000) higher than the statewide figure (139.7 per 100,000). Influenza and
pertussis cases together accounted for about 96 percent of total reported vaccine-preventable
illnesses in upstate New York and 93 percent of total reported preventable illnesses statewide.
Central New York had the highest number of reported vaccine-preventable cases (4,236) and the
highest vaccine-preventable rate (392.3 per 100,000), compared to other upstate New York regions.
In upstate New York in 2012, the influenza rate was highest in Central New York (358.1 per 100,000),
and the pertussis rate was highest in the Southern Tier (47.5 per 100,000).
8584-14CC
A nonprofit independent licensee of the Blue Cross Blue Shield Association
1 of 29
Fall 2014
The vital role of vaccines in public health
Vaccines have been pivotal to safely and effectively controlling — even eradicating — infectious diseases and are aptly ranked among the top public health prevention strategies.3 The CDC estimates
that for each group of children of the same age who are immunized, the return on investment for
childhood immunization is:
• 33,000 lives saved
• $9.9 billion in health care costs saved
• 14 million cases prevented
• $33.4 billion in indirect costs saved4
If the vaccinations in use today were stopped, many diseases that are now controlled could become
common again.5 As an example, almost all Americans contracted measles before the vaccine became
available in 1963. The disease rate decreased more than 99 percent after widespread vaccination. If it
were stopped, rates could increase to those of the pre-vaccine era.6 If vaccinations were eliminated,
preventable diseases could resurge and threaten future generations.
Even with vaccines available, Americans still contract vaccine-preventable illnesses, such as pneumonia
and influenza. About 42,000 adults and 300 children die from vaccine-preventable illnesses in the
U.S. every year.7
About this report
The purpose of this report is to document the incidence of vaccine-preventable diseases, closely
examine prevalent diseases and their deleterious effects (such as hospitalizations and deaths) and
analyze the progress in improving immunization rates in upstate New York, New York state and the U.S.
Common vaccine misconceptions, compiled by the Centers for Disease Control and Prevention,
World Health Organization and the College of Physicians of Philadelphia, also appear throughout
this report.
The report includes available data for the years 2011 through 2012 and a regional analysis, which
describes:
• The reported cases of vaccine-preventable diseases during 2012;
• The hospitalizations caused by pneumonia and/or influenza from 2009 through 2011 and
deaths from pneumonia in 2011;
• The pertussis incidence rates from 2010-2012, including the national outbreak in 2012;
• The self-reported immunization rates for influenza, pneumonia and tetanus and/or pertussis
in 2011;
• The upstate New York, New York state and national childhood immunization rates*
(ages 19 months to 35 months) in 2011.
*Childhood immunization rates include the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella and pneumococcal conjugate vaccines.
A guide to vaccines, vaccinations, and immunizations
• Vaccine: Product that produces immunity from a disease, administered through needle
injections, by mouth, or by aerosol.
• Vaccination: Injection of a killed or weakened organism that produces immunity in the
body against that organism.
• Immunization: Process of becoming protected from a disease. Vaccines cause immunization. Some diseases also cause immunization after an individual recovers from the disease.
Source: The National Vaccine Program Office in the U.S. Department of Health and Human Services. Vaccines.gov basics
http://www.vaccines.gov/basics/index.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
2 of 29
Fall 2014
Key findings
With the exception of influenza and pertussis, very few vaccine-preventable diseases were reported
statewide during 2012, and the adult self-reported immunization rates in 2011 were below 2017
state and 2020 national goals.
• Influenza incidence was higher in upstate New York (225.7 per 100,000) than New York state (113.2 per 100,000) in 2012.
• In 2011, 32.6 percent of upstate New York adults ages 18 to 64 reported having a seasonal
flu shot within the previous year, whereas 61.7 percent of adults 65 and older reported
having the vaccine. Adults ages 18 to 24 reported the lowest vaccination rate (18.8 percent).
• Upstate New York adults reported low rates of pneumococcal lifetime vaccination
(30.9 percent); 11.5 percent reported not knowing if they had received a pneumococcal
vaccination.
• Due to the nationwide pertussis outbreak in 2012, pertussis rates across the country were high.
Compared to the 50 states and District of Columbia, upstate New York ranked 14th-highest in
pertussis incidence (26.6 per 100,000) and was higher than the state rate (16.2 per 100,000) and
national rate (15.4 per 100,000).
• Upstate New York’s childhood immunization rate* (54.5 percent) was lower than the state rate
(65.1 percent) and national rate (68.5 percent) in 2011.
*Childhood immunization rates include the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella and pneumococcal conjugate vaccines.
#1
MISCONCEPTION
Better hygiene and sanitation
are the cause of disease
reduction, not vaccines.
FACT
Improved
socioeconomic
conditions, better nutrition
and advances in antibiotics
have undoubtedly decreased
the disease rate and increased disease survival rates.
However data before and after vaccine availability indicate
that the largest drop in disease rates occurs after vaccine
implementation. According to the CDC and WHO, if
vaccinations were stopped, uncommon and deadly diseases
such as polio and measles would re-emerge.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
3 of 29
Fall 2014
Vaccine-preventable diseases before and after vaccines were
licensed in the United States
Pre-vaccine era cases:
100,000 to 200,000 cases each year in the
1920’s. More than 15,000 deaths in 1921
Post-vaccine era cases (2012):
1 case
{
Diphtheria
1923
1937
Pre-vaccine era cases:
500,000 deaths from “Spanish flu”
in 1918-1919
Post-vaccine era cases (2012):
Since mid-1980’s deaths of
3,000 to 49,000 each year
{
Influenza
Post-vaccine era cases (2012):
0 cases
Pre-vaccine era cases:
Estimated 212,000 cases in 1964
Post-vaccine era cases (2012):
229 cases
Pre-vaccine era cases:
Children had 700 cases of meningitis,
13,000 blood infections, five million ear
infections and 200 deaths each year.
Post-vaccine era cases (2012):
15,635 cases
{
{
Pre-vaccine era cases:
Average of 20,000 severe cases per year
amongchildren younger than five and
1,000 deaths
Post-vaccine era cases (2012):
30 cases among children younger than five
(lockjaw)
1945
1949
Pre-vaccine era cases:
13,000 to 20,000 cases per year
{
{
Polio
Pertussis
Measles
1967
Rubella
(German
measles)
1995
{
{
1977
1981
Haemophilus
Influenzae
Type (Hib)
{
1955
1969
Pneumococcal
Post-vaccine era cases (2012): 37 cases
(whooping cough)
1963
Mumps
{
Tetanus
Pre-vaccine era cases: 1922-1926: estimated
1,314 cases per year, 20% of cases end in death
Hepatitis B
(chicken pox)
Sources: See Data sources and methods
A nonprofit independent licensee of the Blue Cross Blue Shield Association
Post-vaccine era cases (2012): 48,277
cases (considered a cyclical outbreak and
the greatest number of cases since 62,786
were reported in 1955)
Pre-vaccine era cases: Nearly every American
had measles. Each year 3 - 4 million cases and
hundreds died
Post-vaccine era cases (2012):
34 indigenous cases, 21 imported cases
Pre-vaccine era cases: 1964-1965: 12.5 million
infected, 2,000 neonatal deaths, 11,000 miscarriages
Post-vaccine era cases (2012): 9 rubella cases,
3 rubella congenital syndrome cases
{
1985
Varicella
Pre-vaccine era cases: 147,000 reported
cases and about 8,000 deaths each year in
the early 1940’s.
{
Pre-vaccine era cases: 26,000 cases
reported each year in the 1980’s
Post-vaccine era cases (2012):
2,895 cases, 40 perinatal cases
Pre-vaccine era cases: Nearly all Americans had
varicella (4 million cases, 11,000 hospitalizations,
100 deaths per year)
Post-vaccine era cases (2012): 13,447 cases,
3 deaths
4 of 29
Fall 2014
Reported vaccine-preventable diseases among all New Yorkers
Upstate New York rates higher than New York state rates, 2012
250
225.7
Incidence per 100,000
200
150
113.2
100
50
26.6
16.2
us
an
Te
t
ca
l
oc
oc
eu
m
is
be
lla
Ru
ss
rtu
Pe
um
M
cc
co
go
Pn
He
pa
tit
M
is
en
in
ps
al
s
sle
ea
M
en
za
flu
Pe
B
In
rin
Ac
B
is
tit
pa
He
at
al
ut
e
A
is
tit
pa
He
Di
ph
th
er
ia
0
Upstate New York
New York state
Source: New York State Department of Health, 2012 Communicable Disease Annual Reports. “Reported Cases by Disease and County – 2012.”
http://www.health.ny.gov/statistics/diseases/communicable/2012/
Population data: The U.S. Census Bureau
The low vaccine-preventable illness rates in upstate New York and statewide can be attributed to
effective infectious disease control, including use of vaccines.
• Across New York state, the year 2012 witnessed low to nonexistent rates for diphtheria,
hepatitis A, hepatitis B, measles, meningococcal, mumps, rubella and tetanus, with slightly higher pneumococcal rates (.9 per 100,000).
• Upstate New York’s influenza rate (225.7 per 100,000) was twice the state rate
(113.2 per 100,000).
• A national pertussis outbreak resulted in higher rates in upstate New York (26.6 per 100,000)
than New York state (16.2 per 100,000). (Refer to pertussis section for further details.)
#2
MISCONCEPTION
Vaccine-preventable diseases
are close to being eliminated
in the United States, so
vaccination is not necessary.
FACT
Vaccines have reduced the
number of vaccine-preventable
diseases, and some are at
very low levels in the United
States, however some are still prevalent in the country and
epidemic in the world. Travelers can unknowingly bring a
disease to the U.S. The CDC and WHO recommend vaccination
as the best method of protection. Some individuals cannot
be vaccinated for medical reasons and rely on others to be
vaccinated to ensure disease prevention.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
5 of 29
Fall 2014
Influenza and pertussis accounted for the majority of
vaccine-preventable disease instances (per 100,000 people)
across upstate New York regions in 2012
10.7
Central
New York
358.1
23.9
13.7
Finger Lakes
208.0
27.3
12.6
Utica/Rome/
North Country
349.7
23.8
11.6
Southern Tier
263.8
47.5
10.3
Western
New York
71.5
22.7
0
50
100
150
200
250
300
350
400
Incidence per 100,000
All other vaccine-preventable diseases*
Pertussis
Influenza
* Other vaccine-preventable diseases include diphtheria, hepatitis A, hepatitis B acute, hepatitis B perinatal, measles, mumps, meningococcal, pneumococcal, rubella
and tetanus.
Source: New York State Department of Health, Communicable Disease Annual Reports. “Reported Cases by Disease and County – 2012.”
http://www.health.ny.gov/statistics/diseases/communicable/2012/
Population data: The U.S. Census Bureau
Central New York had the highest influenza rate (358.1 per 100,000), and the Southern Tier had the
highest pertussis rate (47.5 per 100,000) in 2012. Western New York had the lowest influenza rate
(71.5 per 100,000) and pertussis rate (22.7 per 100,000) compared to the other regions.
#3
MISCONCEPTION
Vaccine “hot lots” increase
adverse events and deaths.
FACT
The “hot lot” concept is
misused in the vaccine
context, according to the
CDC and WHO. There is no
evidence that one vaccine batch is more or less safe than
another. Vaccine reactions are reported to the federal
government’s Vaccine Adverse Event Reporting System, which
shows that no vaccine lot in the modern era has been
deemed unsafe. The Food and Drug Administration licenses
vaccine manufacturing facilities and vaccine products and can
immediately recall a lot if it’s found to be unsafe.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
6 of 29
Fall 2014
A closer look at prevalent vaccine-preventable diseases:
Influenza and many pneumonia cases
There are various causes of pneumonia, including vaccine-preventable pneumococcal disease, which
is one of the most common causes of severe pneumonia.8
Pneumonia and influenza combined were once the leading causes of death among Americans. In
2011, pneumonia was the ninth leading cause of death, and influenza was the seventh leading cause
of death among adults age 65 and older.9
Every year in America, influenza causes an average of 200,000 hospitalizations and 23,600 deaths.
About 90 percent of deaths due to influenza complications occur in people 65 years and older.10
In the United States in 2010, pneumonia led to 1.1 million hospitalizations and 50,000 deaths.11
Since at least 2002 in New York state, pneumonia and influenza together have been the fifth leading cause of death among females and adults age 75 and older. Among upstate New York females
during 2012, pneumonia and influenza together were the fifth leading cause of death in Broome,
Cayuga, Essex, Fulton, Orleans, and Steuben counties.12 Among upstate New York males during
2012, pneumonia and influenza together were the fourth leading cause of death in Genesee County
and fifth leading cause of death in Allegany, Chenango, Delaware and Montgomery counties.13
FACT
#4
MISCONCEPTION
The majority of people who
get a disease have been
vaccinated.
That statement, while technically true, is grossly misleading
because it is only a fraction
of a percent of those who
are vaccinated who are at risk of getting the disease while
100 percent of those who are unvaccinated are at risk. Most
vaccines are 85-95 percent effective. During outbreaks, more
vaccinated people contract the disease than unvaccinated
people because the raw number of vaccinated people in the
United States is far greater than those who are unvaccinated.
According to the CDC and WHO, if measles were to break out
in a high school with 1,000 students who never had the
disease, the five students who didn’t have two doses of the
measles vaccine would all contract the disease. Of the 995
fully vaccinated students, only seven students, or about 0.7
percent, would become infected. Using this example, vaccine
critics would be misleading if they simply said seven students
who were vaccinated got the disease but only five unvaccinated students got the disease because they did not tell the
rest of the key facts.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
7 of 29
Fall 2014
Pneumonia hospitalizations (rates per 10,000) and deaths (rates per 100,000)
in upstate New York and New York state, 2009-2011
New York State
Hospitalizations:
Pneumonia/flu, age 65+:
Pneumonia, age 0-4:
Pneumonia deaths, 2011:
Upstate New York
96,647 (122.3)
15,982 (45.1)
4,808 (24.6)
Hospitalizations:
Pneumonia/flu, age 65+:
Pneumonia, age 0-4:
Pneumonia deaths, 2011:
32,946 (148.4)
3,079 (37.4)
1,119 (22.6)
Central New York Region
Hospitalizations:
Pneumonia/flu, age 65+:
Pneumonia, age 0-4:
Pneumonia deaths, 2011:
7,494 (174.7)
746 (39.6)
218 (20.2)
Sources: New York State Department of
Health. “Pneumonia/flu hospitalization
rate (Aged 65 years and older) per 10,000.”
http://www.health.ny.gov/statistics/chac/
hospital/h13.htm
New York State Department of Health.
“Pneumonia hospitalization rate per
10,000 – Aged 0-4 years.”
http://www.health.ny.gov/statistics/chac/
hospital/h9.htm
Finger Lakes Region
Hospitalizations:
Pneumonia/flu, age 65+:
Pneumonia, age 0-4:
Pneumonia deaths, 2011:
5,599 (122.8)
492 (27.0)
267 (24.8)
New York State Department of Health.
“Table 38: Selected Causes of Death by
Resident County New York State – 2011.”
https://www.health.ny.gov/statistics/vital_
statistics/2011/table38.htm
Population data: The U.S. Census Bureau
Note: Upstate New York refers to the
New York counties highlighted on this map.
Utica/Rome/North Country Region
Hospitalizations:
Pneumonia/flu, age 65+:
Pneumonia, age 0-4:
Pneumonia deaths, 2011:
Western New York Region
Hospitalizations:
Pneumonia/flu, age 65+:
Pneumonia, age 0-4:
Pneumonia deaths, 2011:
9,091 (125.3)
916 (36.7)
329 (21.4)
6,234 (170.8)
521 (43.2)
165 (21.7)
Southern Tier Region
Hospitalizations:
Pneumonia/flu, age 65+:
Pneumonia, age 0-4:
Pneumonia deaths, 2011:
4,528 (184.7)
404 (48.6)
140 (27.7)
Upstate New York’s three-year pneumonia and influenza hospitalization rate for adults 65 and older
(148.4 per 10,000) was higher than the state rate (122.3 per 10,000). The state’s pneumonia hospitalization rate for children age 0 to 4 (45.1 per 10,000) was higher than upstate New York’s rate (37.4
per 10,000).
The Southern Tier had higher hospitalization rates for both age groups (184.7 per 10,000 adults age
65 and older and 48.6 per 10,000 children ages 0 to 4), compared to the other regions from 2009 to
2011. The Finger Lakes had the lowest hospitalization rates (122.8 per 10,000 adults age 65 and older
and 27.0 per 10,000 children ages 0 to 4). New York state had a higher pneumonia death rate (24.6
per 100,000) than upstate New York (22.6 per 100,000). The Southern Tier region had the highest
pneumonia death rate (27.7 per 100,000) in 2011 compared to other upstate New York regions.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
8 of 29
Fall 2014
Influenza and many pneumonia cases
can be prevented with proper vaccination
At-risk populations
Pneumonia often is a complication of a pre-existing condition or infection, such as influenza.14
Individuals at high risk for becoming sick with pneumonia or developing serious flu-related
complications are:15,16,17
• Adults 65 years and older,
• Children younger than 5 years,
• Individuals with underlying medical conditions,
• Individuals who have asthma.
Other individuals at high risk for developing serious flu-related complications are:18
• Women who are pregnant during flu season,
• Those who are of American Indian and Alaskan native heritage,
• Residents of nursing homes and other chronic care facilities.
Costs
The economic burden of influenza in the U.S. ranges from $71.3 billion to $166 billion, with much of the
cost attributed to indirect costs, such as time off from work and lost productivity.19
Available vaccines
The seasonal flu vaccine protects against influenza,20 and while vaccines cannot prevent every type
of pneumonia, vaccinations are critical to reducing the occurrence of pneumonias. Several vaccines
prevent the bacteria and viruses (including pneumococcus, haemophilus influenzae type b, pertussis,
varicella, measles and influenza) that cause pneumonia.21 Two pneumococcal vaccines protect against
more than 90 types of bacteria that cause pneumonia.22
• Pneumococcal conjugate vaccine is used for children younger than age 2 and adults
with certain immune deficiency conditions.
• Pneumococcal polysaccharide vaccine is used for adults 65 and older, children and younger
adults with high-risk conditions and adults 19 to 64 who smoke or have asthma.23
Influenza vaccination goals
24,25
Program
Population
Target
Healthy People 2020
• Ages 6 months* to 64 years, including pregnant women
80%
Healthy People 2020
• High-risk (noninstitutionalized) adults ages 18 to 64 years
90%
• Institutionalized adults (18 and older)
• Adults 65 and older
• Health care personnel
New York State Prevention
Agenda 2013-2017
• Adults ages 65 and older
75.1%
*Note: children ages 6 months to 23 months may receive one to two doses, depending on age appropriateness and previous doses received
A nonprofit independent licensee of the Blue Cross Blue Shield Association
9 of 29
Fall 2014
Self-reported influenza vaccination rates in upstate New York, 2011
Higher rates among older adults, but rates are still below nationwide goals
100%
Healthy People 2020 target, ages 65+, 90%
Healthy People 2020 target, ages 18-64, 80%
Percent immunized
80%
71.7%
40%
62.1%
61.7%
60%
61.7%
60.6%
51.2%
32.6%
34.3%
36.4%
28.3%
34.7%
29.5%
20%
0%
Upstate
New York
Central
New York
Finger Lakes
Ages 18-64
Southern Tier
Utica/Rome/
North Country
Western
New York
Ages 65+
Source: New York State Department of Health, Behavioral Risk Fact Surveillance System, 2011.
To request access: http://www.health.ny.gov/statistics/brfss/
In 2011, all regional upstate New York self-reported influenza vaccination rates were below the
national goal of having a 90 percent flu immunization rate among adults age 65 and older and the
national goal of having an 80 percent immunization rate among people ages 18 to 64. Adults ages
65 and older were also below the New York state goal of having a 75.1 percent flu immunization
rate in this age group.
Adults ages 65 years and older had higher self-reported influenza vaccination rates than adults ages
18 to 64 across regions, with the age 65 and older age group’s vaccination rate ranging from 71.7
percent in the Finger Lakes to 51.2 percent in Central New York. The vaccination rates for adults ages
18 to 64 ranged from 36.4 percent in the Finger Lakes to 28.3 percent in the Southern Tier.
Of the parents who responded about the vaccination rates of their children, 53.6 percent reported
that their child had the vaccine in the previous year (data not shown), indicating that adults ages
18 to 64 were more likely to have their children vaccinated against the flu than to have themselves
vaccinated.
#5
MISCONCEPTION
Influenza is just a nuisance,
and the vaccine is not
very effective.
FACT
Influenza kills 300,000 to
500,000 people worldwide
every year. Children, pregnant
women, the elderly and
people with chronic conditions are at a high risk for infection
and death. Influenza vaccination is the best way to ensure
immunity from severe flu and to prevent it from spreading
to others.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
10 of 29
Fall 2014
Rates of upstate New York adults who reported having
the seasonal flu shot in the previous year, by age, 2011
Flu immunization rates increase with age, leaving younger adults unprotected
100%
Healthy People 2020 target, ages 65+, 90%
Healthy People 2020 target, ages 18-64, 80%
Percent immunized
80%
61.7%
60%
44.1%
40%
35.1%
34.1%
Ages 35-44
Ages 45-54
26.9%
20%
0%
18.8%
Ages 18-24
Ages 25-34
Ages 55-64
Ages 65+
Sources: New York State Department of Health, Behavioral Risk Fact Surveillance System, 2011.
To request access: http://www.health.ny.gov/statistics/brfss/
U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. “Immunization and Infectious Diseases.”
http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/Immunization.pdf
Adults ages 18 to 24 had the lowest flu vaccination rates in 2011 (18.8 percent). Immunization
rates generally increased with age, with the highest rate being among adults ages 65 and older
(61.7 percent). Flu shot rates in all age groups were below the Healthy People 2020 goals, and
upstate New Yorkers ages 65 and older were about 13 percentage points below the statewide 2017
goal (75.1 percent).
#6
MISCONCEPTION
Simultaneously giving a
child multiple vaccines for
different diseases causes
harmful side effects and
overloads the child’s
immune system.
FACT
Scientific evidence suggests
that simultaneous vaccinations do not adversely
affect the normal childhood
immune system. The CDC’s Advisory Committee on Immunization
Practices and the American Academy of Pediatrics recommends
concurrent administration.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
11 of 29
Fall 2014
Self-reported pneumococcal vaccination rates of adults in upstate New York,
2011
100%
Percent immunized
80%
Low rates across all regions
11.5%
9.9%
11.1%
10.4%
10.6%
13.5%
57.6%
59.3%
60.5%
69.9%
53.4%
52.8%
30.9%
30.8%
35.9%
28.3%
33.7%
Utica/Rome/
North Country
Western
New York
60%
40%
20%
19.7%
0%
Upstate
New York
Central
New York
Finger Lakes
Yes
No
Southern Tier
Not sure/don’t know
Sources: New York State Department of Health, Behavioral Risk Fact Surveillance System, 2011.
To request access: http://www.health.ny.gov/statistics/brfss/
The proportion of upstate New York adults who reported ever having a pneumococcal vaccine was
only 30.9 percent, and 11.5 percent were unsure or did not know, indicating a lack of awareness
about personal immunizations.
The Utica/Rome/North Country region had the highest self-reported lifetime pneumococcal vaccination rate (35.9 percent), and the Southern Tier had the lowest rate (19.7 percent), which was almost 10
percentage points lower than the rate in any other region.
The “not sure/don’t know” percentage among respondents was about 10 percent in all regions, with
the highest rate (13.5 percent) being in Western New York.
Pneumococcal vaccination goals
26,27
Program
Population
Target
Healthy People 2020
• High-risk (noninstitutionalized) adults ages 18 to 64 years
60%
Healthy People 2020
• Children ages 19 months to 35 months
(at least 4 doses of pneumococcal conjugate vaccine)
90%
• Institutionalized adults (18 and older) in long-term care
or nursing homes
• Adults ages 65 and older
New York State Prevention
Agenda 2013-2017
• Adults ages 65 and older
A nonprofit independent licensee of the Blue Cross Blue Shield Association
71.7%
12 of 29
Fall 2014
Self-reported pneumococcal vaccination rates in upstate New York, by age, 2011
Low imunization rates among adults younger than 65
4.2%
100%
Percent immunized
80%
19.1%
63.6%
13.8%
23.2%
7.4%
70.1%
68.0%
7.9%
61.9%
63.5%
25.2%
70.6%
60%
40%
20%
17.6%
0%
Ages 18-24
22.6%
18.2%
13.2%
Ages 25-34
Ages 35-44
Yes
No
Ages 45-54
30.2%
Ages 55-64
Ages 65+
Not sure/don’t know
Sources: New York State Department of Health, Behavioral Risk Fact Surveillance System, 2011.
To request access: http://www.health.ny.gov/statistics/brfss/
In the U.S., adults account for 90 percent of pneumococcal cases and more than 95 percent of
pneumococcal deaths.28 The disease can kill one in four to five people ages 65 and older.29
• The lowest self-reported pneumococcal vaccination percentage among upstate New Yorkers was among adults ages 25 to 34 (13.2 percent), which was the age group that had the
highest percent of people not knowing if they had ever received the vaccine (23.2 percent).
• The self-reported pneumococcal vaccination rate was highest among adults 65 and older,
as 70.6 percent reported having had the vaccine in their lifetime, and only 4.2 percent
reported being unsure. This age group nearly reached the state 2017 goal of 71.7 percent.
• Despite having a higher rate, the percent of 65 and older upstate New Yorkers who had the
pneumococcal vaccination is still short of the Healthy People 2020 goal of having 90 percent
of people vaccinated.
#7
MISCONCEPTION
Vaccines cause autism.
FACT
A 1998 study that is now
discredited raised concerns
about the measles, mumps
and rubella vaccine causing
autism. The journal, The Lancet, that published the original
study removed the article in 2010 after finding it to be
fraudulent. The author lost his license to practice medicine.
The scare led to decreased MMR vaccination rates and
increased outbreaks.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
13 of 29
Fall 2014
A closer look at prevalent vaccine-preventable diseases:
Pertussis (whooping cough)
Pertussis spiked in 2012, the year of the largest national outbreak since 1955
Highly contagious, severe outcomes
Pertussis is a respiratory illness spread by coughing, sneezing and close contact among people. It
can cause life-threatening complications in infants and children and complications from coughing in
adults.30 About 50 percent of infected infants younger than 1 year are hospitalized.31 Of hospitalized
infants, serious complications include:32
• Apnea (67 percent)
• Pneumonia (23 percent)
• Convulsions (1.6 percent)
• Death (1.6 percent)
• Encephalopathy (0.4 percent)
An infected person can spread the disease to up to 15 people, and unvaccinated children are eight
times more likely to become infected than children who receive the five recommended vaccine
doses.33 The disease most commonly affects infants and young children, who get it when it’s passed
on by household members:
• Mothers are responsible for 30 percent to 40 percent of infant cases;34
• Household members are responsible for 80 percent of infant infections.35
[
1 infected person
can spread the disease to up to15 people
A nonprofit independent licensee of the Blue Cross Blue Shield Association
14 of 29
Fall 2014
Vaccination
Before pertussis immunization began in the 1940s, it was one of the most widespread childhood diseases. The U.S. had more than 200,000 cases each year.36 Now, after years of widespread vaccination,
the disease typically affects 10,000 to 40,000 people, and 10 to 20 deaths are reported annually. A
three- to five-year cyclical outbreak trend has been evident since the 1980s. The CDC reports that the
high incidence trend may be due to increased awareness, improved diagnostic tests and reporting,
more bacteria in circulation and fading immunity.37
Recent outbreak
In 2012, the U.S. experienced the largest pertussis outbreak since 1955, demonstrating the three- to
five-year cyclical nature of the disease. Compared to the 50 states and District of Columbia, New York
state’s incidence (16.2 per 100,000) ranked 18th highest, and upstate New York’s incidence (26.6 per
100,000) ranked 14th highest. The New York state and upstate New York incidence rates ranked
higher than the national rate (15.4 per 100,000), which represents 48,277 cases in all.38,39
Available vaccines
• The DTaP (diptheria-tetanus-acellular pertussis) vaccine is given in five doses to children starting at 2 months and continuing through age 6.40
• The Tdap (tetanus-diptheria-accelular pertussis) booster shot is given to preteens, teenagers
and adults in place of one tetanus-diphtheria booster that was to have been given every 10 years.41 The Tdap booster helps maintain immunity and is particularly important for adults who are around infants, due to the highly contagious nature of pertussis.42
The CDC recommends that pregnant women receive the Tdap vaccine during each pregnancy
to protect the baby from whooping cough, because babies are at greatest risk of catching this
potentially deadly disease in their first few weeks of life.43
Pertussis cases and vaccination goals44
Program
Population
Target
Healthy People 2020
• Children younger than 1 year
2,500 cases per year
Healthy People 2020
• Adolescents ages 11 years to 18 years
2,000 cases per year
Healthy People 2020
• Children by age 19 months to 35 months
(4 doses of DTaP)
90%
Healthy People 2020
• Children in kindergarten (4 doses of DTaP)
95%
Healthy People 2020
• Adolescents by age 13 years to 15 years
(1 dose of Tdap booster)
80%
A nonprofit independent licensee of the Blue Cross Blue Shield Association
15 of 29
Fall 2014
Cyclical trend evident: Reported pertussis incidence rate (per 100,000),
2010-2012
Upstate New York rate is higher than state and national rates
30
26.6
Incidence per 100,000
25
20
16.2
15
15.4
10
9.3
9.0
5
4.3
6.5 6.1
2010
2011
6.8
0
New York state
Upstate New York
2012
United States
Sources: New York State Department of Health. “Pertussis incidence per 100,000.”
http://www.health.ny.gov/statistics/chac/general/g30.htm
New York State Department of Health. “Reported Cases by Disease and County: LGV – Pertussis.”
http://www.health.ny.gov/statistics/diseases/communicable/2012/cases/5.htm
Centers for Disease Control and Prevention. “Final 2012 Reports of Nationally Notifiable Infectious Diseases.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6233a6.htm
Centers for Disease Control and Prevention. “Summary of Notifiable Diseases — United States, 2011.”
http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf
Population data: The U.S. Census Bureau
Upstate New York’s reported pertussis incidence rate has been higher than statewide and national
rates since 2010. In 2012, the rates in each geographical area peaked, with the upstate New York
rate (26.6 per 100,000) being almost double that of the state (16.2 per 100,000) and nation (15.4 per
100,000).
A nonprofit independent licensee of the Blue Cross Blue Shield Association
16 of 29
Fall 2014
Self-reported adult diphtheria-tetanus-acellular pertussis booster
immunization rates, upstate New York, 2011
Have you received a tetanus
shot in the past 10 years?
75.3%
Did your doctor say your recent
tetanus shot included the pertussis
or whooping cough vaccine?
15.2%
24.8%
0%
20%
40%
16.2% 8.5%
43.0%
60%
17.0%
80%
100%
Percent immunized
Yes
No
Not sure/don’t know
Doctor didn’t say
Sources: New York State Department of Health, Behavioral Risk Fact Surveillance System, 2011.
To request access: http://www.health.ny.gov/statistics/brfss/
• A majority of upstate New York adults (75.3 percent) reported having had a tetanus shot in
the past 10 years, and 8.5 percent were unsure whether they had a tetanus shot or not.
• Only 15.2 percent of upstate New York adults reported that their most recent tetanus shot
included the pertussis vaccine; 43 percent reported not knowing if pertussis was included, and 17 percent reported that their doctor did not say whether or not pertussis was included.
#8
MISCONCEPTION
Vaccines cause harmful side
effects, including death.
FACT
According to the CDC and
WHO, vaccines are very safe.
Any adverse events associated
with vaccines are temporary
and minor and can be relieved with acetaminophen. The
low number of deaths caused by vaccines makes it difficult
to statistically calculate risk. A person is much more likely to
be severely injured by a vaccine preventable disease than by
a vaccine.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
17 of 29
Fall 2014
Childhood immunization: Importance of disease prevention
The CDC Advisory Committee on Immunization Practices and the state recommend and require child
immunizations to reduce and/or eliminate the number of serious or life-threatening vaccine-preventable illnesses. The recommended vaccine schedule is designed to build babies’ immune systems
in case of disease exposure. Hundreds of research projects conducted by the medical community,
government and nonprofit organizations have continuously proven vaccine safety and effectiveness,45
however highly publicized false claims have led to decreased immunization rates and increasing
measles, mumps and pertussis outbreaks.46
To prevent communicable illnesses, statewide laws require children to receive certain vaccines before
entering child care facilities and/or school, starting with kindergarten and continuing through their
college years.
New York state immunization requirements for school entrance/attendance:
2014-2015 school year
Prekindergarten (Day care, Head
Start, Nursery or Pre-k)
Kindergarten
Diphtheria and tetanus toxoid-containing
vaccine and pertussis vaccine (DTaP/DTP/Tdap)
4 doses
4 to 5 doses
Polio vaccine (IPV/OPV)
3 doses
3 to 5 doses
Measles, mumps and rubella vaccine (MMR)
1 dose
1 dose
Hepatitis B vaccine
3 doses
3 doses
Varicella (chicken pox) vaccine
1 dose
2 doses
Haemophilus influenzae type b conjugate
vaccine (Hib)
1 to 4 doses
Not applicable
Pneumococcal conjugate vaccine (PCV)
1 to 4 doses
Not applicable
Vaccines
Source: New York State Department of Health/Bureau of Immunization. “2014-15 School Year New York State Immunization Requirements for School Entrance/Attendance.”
http://www.health.ny.gov/publications/2370.pdf
New York state and the nation have set goals to increase child immunization rates, including the
recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella and PCV vaccines, otherwise
referred to as the 4:3:1:3:3:1:4 series.
State and national goals for the recommended immunization series*47,48
Program
Population
Target
Healthy People 2020
• Children ages 19 months to 35 months
80%
New York State Prevention Agenda
2013-2017
• Children ages 19 months to 35 months
80%
* 4:3:1:3:3:1:4 immunization series includes 4+ doses of DTaP, 3+ doses of polio, 1+ dose of MMR, 3+ doses of Hib, 3+ doses of Hep B, 1+ dose of varicella,
and 4+ doses of PCV.
The national rate for the recommended vaccination series among children ages 19 months to 35
months was 44.3 percent in 2009 and increased to 68.5 percent in 2011.49 However, New York state
and upstate New York’s percentages are lagging behind the nation and even farther from the 80
percent goal.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
18 of 29
Fall 2014
Reported vaccination* rates among children ages
19 months to 35 months, 2011
Upstate New York rates are lower than New York state and national rates
100%
Healthy People 2020 and NYS Prevention Agenda 2013-2017 goals, 80%
80%
Percent immunized
68.5%
65.1%
60%
54.5%
56.4%
51.9%
56.0%
51.2%
55.9%
40%
20%
0%
United
States
New York
State
Upstate
New York
Central
New York
Finger
Lakes
Southern
Tier
Utica/
Rome/
North
Country
Western
New York
* 4:3:1:3:3:1:4 immunization series includes 4+ doses of DTaP, 3+ doses of polio, 1+ dose of MMR, 3+ doses of Hib, 3+ doses of Hep B, 1+ dose of varicella,
and 4+ doses of PCV.
Sources: New York State Department of Health. “Percentage of children with 4:3:1:3:3:1:4 immunization series - Aged 19-35 months.”
https://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/p30.htm
New York State Department of Health. “New York State Prevention Agenda 2013-2017: Priorities, Focus Areas, Goals and Objectives.”
http://www.health.ny.gov/prevention/prevention_agenda/2013-2017/docs/tracking_indicators.pdf
U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. Healthy People 2020. “Immunization and Infectious Diseases.”
http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/Immunization.pdf
In 2011, the United States and New York state’s vaccination rates for children ages 19 months to 35
months were below the Healthy People 2020 and NYS Prevention Agenda 2013-2017 target rate of
80 percent:
• Upstate New York’s rate (54.5 percent) was more than 10 percentage points lower than the
state rate (65.1 percent) and national rate (68.5 percent).
• Upstate New York’s 2011 regional child vaccination rates ranged from 56.4 percent in
Central New York to 51.2 percent in Utica/Rome/North Country in 2011.
A nonprofit independent licensee of the Blue Cross Blue Shield Association
19 of 29
Fall 2014
Vaccine-preventable disease and vaccination reporting in New York state
Reporting of suspected or confirmed communicable diseases is required by the New York State
Sanitary Code (10NYCRR 2.10). Physicians, school nurses, laboratory directors, infection control
practitioners, day care center directors, health care facilities, state institutions and all other
individuals/locations that provide health care services are required to report communicable diseases.
Communicable vaccine-preventable diseases include diphtheria, hepatitis A, hepatitis B acute,
hepatitis B perinatal, laboratory-confirmed influenza, measles, meningococcal, mumps, pertussis, rubella, pneumococcal and tetanus. The data presented in this report, which are useful for
examining overall trends and at-risk population trends, represent only a portion of the true burden
of vaccine-preventable illnesses in the state. Many cases go undiagnosed, and some highly prevalent
diseases, such as varicella (chicken pox), are not reported at all.50
The New York State Legislature passed the Immunization Registry Law, effective in 2008, which
requires health care providers to report all immunizations administered to individuals ages 18 years
and younger with the person’s immunization histories to the New York State Department of Health
using the New York State Immunization Information System. The data presented in that report may
not represent the true percentages, because some immunizations remain unreported to the New
York State Immunization Information System.51
A nonprofit independent licensee of the Blue Cross Blue Shield Association
20 of 29
Fall 2014
Recommended Immunization Schedules
Adults
The 2014 Adult Immunization Schedule was approved by the Centers for Disease Control and
Prevention’s Advisory Committee on Immunization Practices and the professional societies of family
practice, internal medicine, obstetrics/gynecology and nurse-midwives. The schedule describes the
most current recommendations for adult vaccinations.52
If you are this age,
Talk to your healthcare professional
about these vaccines:
19-21 years
2014 Recommended Immunizations for Adults by Age
22-26 years
Influenza (Flu)
27-49 years
50-59 years
60-64 years
65+ years
Get a flu vaccine every year
1
Tetanus, diphtheria, pertussis (Td/Tdap)
Get a Tdap vaccine once, then a Td booster vaccine every 10 years
2
2 doses
Varicella (Chickenpox)3
HPV Vaccine for Women
3 doses
3,4
HPV Vaccine for Men
3 doses
3,4
3 doses
1 dose
Zoster (Shingles)5
Measles, mumps, rubella (MMR)
3
1 or 2 doses
Pneumococcal (PCV13)7
1 dose
Pneumococcal (PPSV23)7
1 or 2 doses
Meningococcal
1 dose
1 or more doses
Hepatitis A3
2 doses
Hepatitis B3
3 doses
Haemophilus influenzae type b (Hib)
1 or 3 doses
Boxes this color show that
the vaccine is recommended
for all adults who have not
been vaccinated, unless your
healthcare professional tells
you that you cannot safely
receive the vaccine or that you
do not need it.
Boxes this color show when the
vaccine is recommended for
adults with certain risks related
to their health, job or lifestyle
that put them at higher risk for
serious diseases. Talk to your
healthcare professional to see if
you are at higher risk.
No recommendation
FOOTNOTES:
1. Influenza vaccine: There are several flu vaccines available—talk to your healthcare professional about which flu vaccine is right for you.
2. Td/Tdap vaccine: Pregnant women are recommended to get Tdap vaccine with each pregnancy in the third trimester to increase protection for infants who are too young for vaccination, but at highest
risk for severe illness and death from pertussis (whooping cough). People who have not had Tdap vaccine since age 11 should get a dose of Tdap followed by Td booster doses every 10 years.
3. Varicella, HPV, MMR, Hepatitis A, Hepatitis B vaccine: These vaccines are needed for adults who didn’t get these vaccines when they were children.
4. HPV vaccine: There are two HPV vaccines, but only one, HPV (Gardasil®), should be given to men. Gay men or men who have sex with men who are 22 through 26 years old should get HPV vaccine if they
haven’t already started or completed the series.
5. Zoster vaccine: You should get the zoster vaccine even if you’ve had shingles before.
6. MMR vaccine: If you were born in 1957 or after, and don’t have a record of being vaccinated or having had these infections, talk to your healthcare professional about how many doses you may need.
7. Pneumococcal vaccine: There are two different types of pneumococcal vaccines: PCV13 and PPSV23. Talk with your healthcare professional to find out if one or both pneumococcal vaccines are
recommended for you.
If you are traveling outside of the United States, you may need additional vaccines. Ask your healthcare professional which vaccines you may need.
For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines
Source: Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases. “Immunization Schedules for Adults in Easy-to-read Formats.”
Updated May 6, 2014. Web. 30 Aug. 2014.
http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
21 of 29
Fall 2014
Recommended Immunization Schedules (continued)
2014 Recommended Immunizations for Adults by Medical Condition
If you have this health condition,
Pregnancy
Talk to your healthcare professional
about these vaccines:
Weakened
immune system
(not human
immuno­
deficiency virus
[HIV])
HIV Infection
CD4
count
is less
than
200
CD4
count is
200 or
greater
Kidney disease
or poor kidney
function
Influenza (Flu)1
Diabetes
(Type 1 and
Type 2)
Chronic Liver
Disease
Get a flu vaccine every year
Tetanus, diphtheria, pertussis
(Td/Tdap)2
Varicella (Chickenpox)
3
1 dose Tdap
each pregnancy
Get Tdap vaccine once, then a Td booster every 10 years
SHOULD NOT GET VACCINE
2 doses
HPV Vaccine for Women3,4
3 doses through age 26 years
HPV Vaccine for Men3,4
Zoster (Shingles)
Asplenia (if you Heart disease,
do not have
chronic lung
a spleen or it
disease,
does not work
chronic
well)
alcoholism
3 doses through age 26 years
5
SHOULD NOT GET VACCINE
Measles, mumps, rubella (MMR)3,6
SHOULD NOT GET VACCINE
Pneumococcal (PCV13)7
Pneumococcal (PPSV23)7
1 dose for those 60 years and older
1 or 2 doses
1 dose
1 or 2 doses
Meningococcal
Haemophilus influenzae type b (Hib)
1 dose
1 or 2 doses
1 or more doses
1 or more doses
Hepatitis A3
Hepatitis B3
3 doses through age 21 years
1 or more doses
2 doses
3 doses
post-HSCT recipients only
Boxes this color show that
the vaccine is recommended
for all adults who have not
been vaccinated, unless your
healthcare professional tells
you that you cannot safely
receive the vaccine or that you
do not need it.
3 doses
2 doses
3 doses
1 or 3 doses
Boxes this color show when
the vaccine is recommended
for adults with certain risks
related to their health, job
or lifestyle that put them at
higher risk for serious diseases.
Talk to your healthcare
professional to see if you are at
higher risk.
3 doses
1 or 3 doses
Boxes this color indicate the
adult should NOT get this
vaccine.
No recommendation
FOOTNOTES:
1. Influenza vaccine: There are several flu vaccines available—talk to your healthcare professional about which flu vaccine is right for you.
2. Td/Tdap vaccine: Pregnant women are recommended to get Tdap vaccine with each pregnancy in the third trimester to increase protection for infants who are too young for vaccination but at highest risk for severe
illness and death from pertussis (whooping cough). People who have not had Tdap vaccine since age 11 should get a dose of Tdap followed by Td booster doses every 10 years.
3. Varicella, HPV, MMR, Hepatitis A, Hepatitis B vaccine: These vaccines are needed for adults who didn’t get these vaccines when they were children.
4. HPV vaccine: There are two HPV vaccines, but only one, HPV (Gardasil®), should be given to men. Gay men or men who have sex with men who are 22 through 26 years old should get HPV vaccine if they haven’t already
started or completed the series.
5. Zoster vaccine: You should get the zoster vaccine even if you’ve had shingles before.
6. MMR vaccine: If you were born in 1957 or after, and don’t have a record of being vaccinated or having had these infections, talk to your healthcare
professional about how many doses you may need.
7. Pneumococcal vaccine: There are two different types of pneumococcal vaccines: PCV13 and PPSV23. Talk with your healthcare professional to find out if
one or both pneumococcal vaccines are recommended for you.
If you are traveling outside of the United States, you may need additional vaccines. Ask your healthcare professional which vaccines you may need.
For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines
Last updated February 1, 2014 • CS245563-A
Source: Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases. “Immunization Schedules for Adults in Easy-to-read Formats.”
Updated May 6, 2014. Web. 30 Aug. 2014.
http://www.cdc.gov/vaccines/schedules/easy-to-read/adult.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
22 of 29
Fall 2014
Recommended Immunization Schedules (continued)
Children
The recommended schedules for children are reviewed each year. They have been approved by the
Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices and the
professional societies of pediatrics, family physicians and obstetricians and gynecologists. The most
recent was published by the Centers for Disease Control and Prevention in February 2014.53
2014 Recommended Immunizations for Children from Birth Through 6 Years Old
Birth
HepB
1
2
month
months
4
months
6
months
HepB
Is your family
growing? To protect
your new baby and
yourself against whooping
cough, get a Tdap vaccine
in the third trimester
of each pregnancy. Talk
to your doctor for more
details.
you don’t need to start over,
just go back to your child’s
doctor for the next shot.
Talk with your child’s doctor
if you have questions
about vaccines.
15
months
18
months
19–23
months
2–3
years
4–6
years
HepB
RV
RV
RV
DTaP
DTaP
DTaP
Hib
Hib
Hib
Hib
PCV
PCV
PCV
PCV
IPV
IPV
DTaP
DTaP
IPV
IPV
Influenza (Yearly)
*
MMR
MMR
Varicella
Shaded boxes indicate the
vaccine can be given during
shown age range.
NOTE: If your child misses a shot,
12
months
Varicella
HepA
§
FOOTNOTES:
* Two doses given at least four weeks apart are recommended for children aged 6 months through 8 years
of age who are getting a flu vaccine for the first time and for some other children in this age group.
§
Two doses of HepA vaccine are needed for lasting protection. The first dose of HepA vaccine should be
given between 12 months and 23 months of age. The second dose should be given 6 to 18 months later.
HepA vaccination may be given to any child 12 months and older to protect against HepA. Children and
adolescents who did not receive the HepA vaccine and are at high-risk, should be vaccinated against HepA.
If your child has any medical conditions that put him at risk for infection or is traveling outside the
United States, talk to your child’s doctor about additional vaccines that he may need.
See back page
for more
information on
vaccine­
preventable
diseases and the
vaccines that
prevent them.
For more information, call toll free
1-800-CDC-INFO (1-800-232-4636)
or visit
http://www.cdc.gov/vaccines
Source: Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases. “Immunization Schedules for Infants and Children in
Easy-to-read Formats.” Updated Jan. 31, 2014. Web. 30 Aug. 2014
http://www.cdc.gov/vaccines/schedules/easy-to-read/child.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
23 of 29
Fall 2014
Recommended Immunization Schedules (continued)
2014 Recommended Immunizations for Children from 7 Through 18 Years Old
7–10 YEARS
11-12 YEARS
Tdap 1
Tetanus, Diphtheria, Pertussis (Tdap) Vaccine
13-18 YEARS
Tdap
HPV
Human Papillomavirus (HPV) Vaccine (3 Doses)
2
MCV4
Meningococcal Conjugate Vaccine (MCV4) Dose 1
3
MCV4 Dose 1
3
Booster at age 16 years
Influenza (Yearly)
4
Pneumococcal Vaccine5
Hepatitis A (HepA) Vaccine Series6
Hepatitis B (HepB) Vaccine Series
Inactivated Polio Vaccine (IPV) Series
Measles, Mumps, Rubella (MMR) Vaccine Series
Varicella Vaccine Series
These shaded boxes indicate when the vaccine is
recommended for all children unless your doctor tells
you that your child cannot safely receive the vaccine.
These shaded boxes indicate the
vaccine should be given if a child is
catching-up on missed vaccines.
These shaded boxes indicate the vaccine is recommended for children with certain health
conditions that put them at high risk for serious diseases. Note that healthy children can get the
HepA series6. See vaccine-specific recommendations at www.cdc.gov/vaccines/pubs/ACIP-list.htm.
FOOTNOTES
Tdap vaccine is combination vaccine that is recommended at age 11 or 12 to protect against tetanus, diphtheria and pertussis. If your child has not received any or all of the DTaP vaccine series, or if you don’t know if your child has received these shots, your child needs a single dose of Tdap when they are 7 -10 years old. Talk to your child’s health care provider to find out if they need additional catch-up vaccines.
2
All 11 or 12 year olds – both girls and boys – should receive 3 doses of HPV vaccine to protect against HPV-related disease. Either HPV vaccine (Cervarix® or Gardasil®) can be given to girls and young women; only one HPV vaccine (Gardasil®) can be given to boys and young men.
3
Meningococcal conjugate vaccine (MCV) is recommended at age 11 or 12. A booster shot is recommended at age 16. Teens who received MCV for the first time at age 13 through 15 years will need a one-time booster dose between the ages of 16 and 18 years. If your teenager missed getting the vaccine altogether, ask their health care provider about getting it now, especially if your teenager is about to move into a college dorm or military barracks.
4
Everyone 6 months of age and older—including preteens and teens—should get a flu vaccine every year. Children under the age of 9 years may require more than one dose. Talk to your child’s health care provider to find out if they need more than one dose. 5
Pneumococcal Conjugate Vaccine (PCV13) and Pneumococcal Polysaccharide Vaccine (PPSV23) are recommended for some children 6 through 18 years old with
certain medical conditions that place them at high risk. Talk to your healthcare provider about pneumococcal vaccines and what factors may place your child at
high risk for pneumococcal disease.
6
Hepatitis A vaccination is recommended for older children with certain medical conditions that place them at high risk. HepA vaccine is licensed, safe, and effective for all children of all ages. Even if your child is not at high risk, you may decide you want your child protected against HepA. Talk to your healthcare provider about HepA vaccine and what factors may place your child at high risk for HepA.
1
For more information, call toll free 1-800-CDC-INFO (1-800-232-4636) or visit http://www.cdc.gov/vaccines/teens
Source: Centers for Disease Control and Prevention. National Center for Immunization and Respiratory Diseases. “Immunization Schedules for Preteens and Teens in
Easy-to-read Formats.” Updated April 24, 2014. Web. 30 Aug. 2014.
http://www.cdc.gov/vaccines/schedules/easy-to-read/preteen-teen.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
24 of 29
Fall 2014
Data sources and methods
Vaccine-preventable disease cases, 2012: New York State Department of Health and Centers for
Disease Control and Prevention
Reported vaccine-preventable illness data in upstate New York and New York state were obtained
from the New York State Department of Health’s 2012 Communicable Disease Annual Reports,
“Reported Cases by Disease and County – 2012.”
http://www.health.ny.gov/statistics/diseases/communicable/2012/
Pneumonia and flu hospitalization and/or death rates, 2009-2011: New York State
Department of Health
Reported pneumonia/influenza hospitalization data in upstate New York and New York state
were obtained from the New York State Department of Health Community Health Indicator
Reports-Communicable Disease Indicators, “Pneumonia/flu hospitalization rate (Aged 65 years
and older) per 10,000” and “Pneumonia hospitalization rate per 10,000 - Aged 0-4 years,”
which are derived from the 2009-2011 Statewide Planning and Research Cooperative System.
http://www.health.ny.gov/statistics/chac/hospital/h13.htm
http://www.health.ny.gov/statistics/chac/hospital/h9.htm
Pneumonia mortality data in upstate New York and New York state were obtained from the New
York State Department of Health’s Vital Statistics of New York State 2011, “Selected Causes of Death
by Resident County New York State, 2011.”
https://www.health.ny.gov/statistics/vital_statistics/2011/table38.htm
Pertussis incidence, 2010-2012: New York State Department of Health and Centers for Disease
Control and Prevention
Upstate New York and New York state pertussis rates were obtained from the New York State
Department of Health Community Health Indicator Reports-Communicable Disease Indicators,
“Pertussis incidence per 100,000” and “Reported Cases by Disease and County: LGV – Pertussis.”
http://www.health.ny.gov/statistics/chac/general/g30.htm
http://www.health.ny.gov/statistics/diseases/communicable/2012/cases/5.htm
National pertussis incidence data were obtained from the Centers for Disease Control and Prevention,
Morbidity and Mortality Weekly Reports, “Summary of Notifiable Diseases-United States, 2011” and
“Final 2012 Reports of Nationally Notifiable Infectious Diseases.”
http://www.cdc.gov/mmwr/pdf/wk/mm6053.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6233a6.htm
Childhood immunization rates: New York State Department of Health
Children ages 19 months to 35 months immunization data were obtained from the New York State
Department of Health’s Indicators for Tracking Public Health Priority Areas, “Percentage of children
with 4:3:1:3:3:1:4 immunization series - Aged 19-35 months,” which was derived from the 2011 New
York State Immunization Information System (NYSIIS) Data.
https://www.health.ny.gov/prevention/prevention_agenda/2013-2017/indicators/2013/p30.htm
Population figures: U.S. Census Bureau
Population figures for upstate New York, used as denominators to calculate vaccine-preventable
disease rates, were obtained from the U.S. Census Bureau:
http://www.census.gov/popest/data/counties/asrh/2012/CC-EST2012-ALLDATA.html
Population figures for the U.S. were obtained from the U.S. Census Bureau:
http://www.census.gov/popest/data/national/totals/2012/index.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
25 of 29
Fall 2014
Data sources and methods (continued)
The vaccine misconceptions were obtained from these sources:
Centers for Disease Control and Prevention. “Some Common Misconceptions.”
http://www.cdc.gov/vaccines/vac-gen/6mishome.htm
World Health Organization. “Six common misconceptions about immunization.”
http://www.who.int/vaccine_safety/initiative/detection/immunization_misconceptions/en/
World Health Organization. “What are some of the myths-and facts-about vaccination?”
http://www.who.int/features/qa/84/en/
The College of Physicians of Philadelphia. “Misconceptions about Vaccines.”
http://www.historyofvaccines.org/content/articles/misconceptions-about-vaccines
American Academy Of Pediatrics. “Policy Statement: Recommendations for the Prevention
of Pneumococcal Infections, Including the Use of Pneumococcal Conjugate Vaccine (Prevnar),
Pneumococcal Polysaccharide Vaccine, and Antibiotic Prophylaxis.”
http://pediatrics.aappublications.org/content/106/2/362.long
Centers for Disease Control and Prevention “Immunization Safety and Autism.”
http://www.cdc.gov/vaccinesafety/00_pdf/CDCStudiesonVaccinesandAutism.pdf
National Research Council “Immunization Safety Review: Vaccines and Autism. ”May 14, 2004
http://www.iom.edu/reports/2004/immunization-safety-review-vaccines-and-autism.aspx
Adult immunization rates: New York State Department of Health’s Behavioral Risk Factor
Surveillance System
The adult immunization figures in this report were obtained from the 2011 New York State
Department of Health’s Behavioral Risk Factor Surveillance System. This is an ongoing, statebased, random telephone survey of the non-institutionalized civilian adult population ages 18 and
older. State and national data are compiled and reported by the Centers for Disease Control and
Prevention.
The BRFSS questionnaire asks respondents:
• “Now I will ask you questions about seasonal flu vaccine. There are two ways to get the
seasonal flu vaccine, one is a shot in the arm and the other is a spray, mist, or drop in the
nose called FluMist™. During the past 12 months, have you had either a seasonal flu shot
or a seasonal flu vaccine that was sprayed in your nose?
• During the past 12 months, has [your child, he/she] had a seasonal flu vaccination? There
are two types of flu vaccinations. One is a shot and the other is a spray in the nose.
• A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person’s
lifetime and is different from the flu shot. Have you ever had a pneumonia shot?
• Have you received a tetanus shot in the past 10 years?
• There are currently two types of tetanus shots available for adults. One contains the tetanus
diphtheria vaccine. The other type contains tetanus diphtheria and pertussis or whooping
cough vaccine. Did your doctor say your recent tetanus shot included the pertussis or
whooping cough vaccine?”
To request access to the BRFSS data: http://www.health.ny.gov/statistics/brfss/
A nonprofit independent licensee of the Blue Cross Blue Shield Association
26 of 29
Fall 2014
Data sources and methods (continued)
The vaccine time line and history of pre-vaccination and post-vaccination eras drawn from these
multiple sources:
Atkinson, W. Wolfe, C. and Hamborsky, J. Centers for Disease Control and Prevention. Epidemiology
and Prevention of Vaccine-Preventable Diseases (The Pink Book: Course Textbook). 12th Edition, 2nd
printing. May 2012 update.
http://www.cdc.gov/vaccines/pubs/pinkbook/index.html
Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. “Notice to
Readers: Final 2012 Reports of Nationally Notifiable Infectious Diseases.”
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6233a6.htm
Centers for Disease Control and Prevention. “What Would Happen If We Stopped Vaccinations?”
http://www.cdc.gov/vaccines/vac-gen/whatifstop.htm
Immunization Action Coalition. Questions and Answers Information about the disease and vaccines for
chickenpox (varicella), diptheria, haemophilus influenzae type b (hib), measles, mumps,
pneumococcus, polio, tetanus
http://www.immunize.org/
Immunization Action Coalition. “Vaccine Timeline.”
http://www.immunize.org/timeline/
WebMD. Causes and Evolution of Influenza (Flu). Reviewed by David T. Derrer, MD on August 16, 2014
http://www.webmd.com/cold-and-flu/information-influenza
A nonprofit independent licensee of the Blue Cross Blue Shield Association
27 of 29
Fall 2014
Endnotes
1 Centers for Disease Control and Prevention. “Vaccines and Preventable Diseases.” Vaccines and Immunizations. National Center for Immunization and Respiratory
Diseases. March 14, 2012. Web. 21 Feb. 2014.
http://www.cdc.gov/VACCINES/vpd-vac/
2 Centers for Disease Control and Prevention. “Basics and Common Questions: Why Immunize?” Vaccines and Immunizations. National Center for Immunization
and Respiratory Diseases. March 14, 2012. Web. 21 Feb. 2014.
http://www.cdc.gov/vaccines/vac-gen/why.htm/
3 New York State Department of Health. “Focus Area 2: Prevent Vaccine-Preventable Diseases.” Prevention Agenda 2013-2017. June 2013. Web. 25 Feb. 2013.
https://www.health.ny.gov/prevention/prevention_agenda/2013-2017/plan/stds/focus_area_2.htm
4 Healthy People 2020. “Immunization and Infectious Diseases: Overview.” 2020 Topics and Objectives. U.S. Department of Health and Human Services.
Nov., 13 2013. Web. 25 Feb. 2014.
http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=23
5 Centers for Disease Control and Prevention. “What Would Happen If We Stopped Vaccinations?” Vaccines and Immunizations. National Center for Immunization
and Respiratory Diseases. September 18, 2013. Web. 26 Feb. 2014.
http://www.cdc.gov/vaccines/vac-gen/whatifstop.htm
6 National Network for Immunization Information. “Measles, Mumps, Rubella (MMR).” Updated: April 21, 2010. Web. 17 Aug. 2014.
http://www.immunizationinfo.org/vaccines/measles
7 Healthy People 2020. “Immunization and Infectious Diseases: Overview.”
8 Centers for Disease Control and Prevention. “Types of Infection.” Pneumococcal Disease. June 6, 2013. Web. 9 July 2014.
http://www.cdc.gov/pneumococcal/about/infection-types.html
9 Multack, M. and Flowers, L. “Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries.” AARP Public Policy
Institute. May 2012. Web. 18 Mar. 2014.
http://www.aarp.org/content/dam/aarp/research/public_policy_institute/health/2011/racial-and-ethnic-disparities-in-immunization-rates-among-medicarebeneficiaries-AARP-ppi-health.pdf
10 New York State Department of Health. “Influenza (Flu) Fact Sheet.” Seasonal Influenza. October 2013. Web. 19 May 2014.
https://www.health.ny.gov/diseases/communicable/influenza/fact_sheet.htm
11 Centers for Disease Control and Prevention. “Pneumonia Can Be Prevented - Vaccines Can Help.”
12 New York State Department of Health. “Leading Causes of Death Among Females by County, New York State, 2011.” New York State Department of Health,
Bureau of Biometrics and Health Statistics. March 2013. Web. 24 Feb. 2014.
http://www.health.ny.gov/statistics/leadingcauses_death/women_by_county.htm
13 New York State Department of Health. “Leading Causes of Death Among Males by County, New York State, 2011.” New York State Department of Health,
Bureau of Biometrics and Health Statistics. March 2013. Web. 24 Feb. 2014.
http://www.health.ny.gov/statistics/leadingcauses_death/men_by_county.htm
14 American Lung Association. “Pneumonia Fact Sheet.” Lung Disease. Web. 24 Feb. 2014.
http://www.lung.org/lung-disease/influenza/in-depth-resources/pneumonia-fact-sheet.html
15 New York State Department of Health. “Influenza (Flu) Fact Sheet.”
16 Centers for Disease Control and Prevention. “Pneumonia Can Be Prevented – Vaccines Can Help.” National Center for Emerging and Zoonotic Infectious Diseases.
Feb.18, 2014. Web. 19 May 2014.
http://www.cdc.gov/features/pneumonia/
17 New York State Department of Health. “Influenza (Flu) Fact Sheet.”
18 Ibid.
19 Pharmaceutical Research and Manufacturers of America. “Vaccines Fact Book 2013.” September 2013. Web. 19 May 2014.
http://www.slideshare.net/PhRMA/ph-rma-vaccinefactbook2013
20 New York State Department of Health. “Influenza (Flu) Fact Sheet.”
21 Centers for Disease Control and Prevention. “Pneumonia Can Be Prevented - Vaccines Can Help.”
22 Centers for Disease Control and Prevention. “Prevention.” Pneumococcal Disease. National Center for Immunization and Respiratory Diseases,
Division of Bacterial Diseases. June 6, 2013. Web. 28 Feb. 2014.
http://www.cdc.gov/pneumococcal/about/prevention.html
23 Ibid.
24 Healthy People 2020. “Immunization and Infectious Diseases: Objectives.” 2020 Topics and Objectives. U.S. Department of Health and Human Services.
Nov. 13, 2013. Web. 25 Feb. 2014.
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23
25 New York State Department of Health. “Focus Area 2: Prevent Vaccine-Preventable Diseases.”
26 Healthy People 2020. “Immunization and Infectious Diseases: Objectives.” 2020 Topics and Objectives. U.S. Department of Health and Human Services.
Nov. 13, 2013. Web. 25 Feb. 2014.
http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23
27 New York State Department of Health. “Focus Area 2: Prevent Vaccine-Preventable Diseases.”
28 Centers for Disease Control and Prevention. “Fast Facts.” Pneumococcal Disease. National Center for Immunization and Respiratory Diseases, Division of
Bacterial Diseases. June 6, 2013. Web. 14 May 2014.
http://www.cdc.gov/pneumococcal/about/facts.html
29 National Foundation for Infectious Diseases. “Pneumococcal Disease.” N. d. Web. 14 May 2014.
http://www.adultvaccination.com/pneumococcal_vaccine_vaccination_adult_immunization.htm
30 Centers for Disease Control and Prevention. “Causes & Transmission.” Pertussis (Whooping Cough). National Center for Immunization and Respiratory Diseases,
Division of Bacterial Disease. August 28, 2013. Web. 26 Feb. 2014.
http://www.cdc.gov/pertussis/about/causes-transmission.html
31 Centers for Disease Control and Prevention. “Complications.” Pertussis (Whooping Cough). National Center for Immunization and Respiratory Diseases,
Division of Bacterial Diseases. August 28, 2013. Web. 26 Feb. 2014.
http://www.cdc.gov/Pertussis/about/complications.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
28 of 29
Fall 2014
32 Ibid.
33 Centers for Disease Control and Prevention. “Pertussis Frequently Asked Questions.” National Center for Immunization and Respiratory Diseases, Division of Bacterial
Diseases. Dec. 19, 2013. Web. 19 May 2014.
http://www.cdc.gov/pertussis/about/faqs.html
34 Centers for Disease Control and Prevention. “Get Whooping Cough Vaccine While You Are Pregnant.” National Center for Immunization and Respiratory Disease.
Jan. 17, 2014. Web. 19 May 2014.
http://www.cdc.gov/vaccines/adults/rec-vac/pregnant/whooping-cough/get-vaccinated.html
35 Centers for Disease Control and Prevention. “Surround Babies with Protection.” National Center for Immunization and Respiratory Disease. January 17, 2014.
Web. 19 May 2014.
36 Atkinson, W. Wolfe, C. and Hamborsky, J. “Pertussis” Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book: Course Textbook). 12th Edition,
2nd printing. May 2012 update Page 215. Web. 16 August 2014.
http://www.cdc.gov/vaccines/pubs/pinkbook/pert.html
37 Centers for Disease Control and Prevention. “Pertussis Frequently Asked Questions.”
38 Centers for Disease Control and Prevention. “Notice to Readers: Final 2012 Reports of Nationally Notifiable Infectious Diseases.”
Morbidity and Mortality Weekly Report. Aug. 23, 2013. Web. 5 June 2014.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6233a6.htm
39 New York State Department of Health. “Reported Cases by Disease and County: LGV – Pertussis.” 2012 Communicable Disease Annual Reports.
September 2013. Web. 5 June 2014.
http://www.health.ny.gov/statistics/diseases/communicable/2012/cases/5.htm
40 Centers for Disease Control and Prevention. “Diphtheria, Tetanus, and Pertussis (DTaP) Vaccines.” Vaccine Information Statements.
National Center for Immunization and Respiratory Diseases. May 18, 2013. Web. 25 Feb. 2014.
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/dtap.html
41 Centers for Disease Control and Prevention. “Prevention.” Pertussis (Whooping Cough). National Center for Immunization and Respiratory Diseases,
Division of Bacterial Diseases. Feb. 13, 2014. Web. 25 Feb. 2014.
http://www.cdc.gov/pertussis/about/prevention.html
42 Ibid.
43 Centers for Disease Control and Prevention. “Get Whooping Cough Vaccine While You Are Pregnant.”
44 Healthy People 2020. “Immunization and Infectious Diseases: Objectives.”
45 New York State Department of Health. “The Facts Behind Vaccine Safety.” Vaccine Safety. May 2011. Web. 28 Feb. 2014.
http://www.health.ny.gov/prevention/immunization/vaccine_safety/proof.htm
46 New York State Department of Health. “The Harm of Skipping Vaccinations or Delaying.” Vaccine Safety, April 2012. Web. 28 Feb. 2014.
http://www.health.ny.gov/prevention/immunization/vaccine_safety/harm.htm
47 Healthy People 2020. “Immunization and Infectious Diseases: Objectives.”
48 New York State Department of Health. “Focus Area 2: Prevent Vaccine-Preventable Diseases.”
49 Healthy People 2020. “DATA2020 Search Results: IID-8 Increase the percentage of children aged 19 to 35 months who receive the recommended doses of DTaP, polio,
MMR, Hib, hepatitis B, varicella and pneumococcal conjugate vaccine (PCV).” Immunization and Infectious Diseases. U.S. Department of Health and Human Services.
September 18, 2013. Web. 25 Feb. 2014.
http://www.healthypeople.gov/2020/Data/SearchResult.aspx?topicid=23&topic=Immunization%20and%20Infectious%20Diseases&objective=IID-8&anchor=565%20%20
50 New York State Department of Health. Communicable Disease Reporting. Web. 27 Aug. 2014.
https://www.health.ny.gov/professionals/diseases/reporting/communicable
51 New York State Department of Health. New York State Immunization Information System (NYSIIS). Web. 27 Aug. 2014.
https://www.health.ny.gov/prevention/immunization/information_system/
52 Bridges, CB, Coyne-Beasley, T. “Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older:
United States, 2014.” Annals of Internal Medicine. 2014;160(3):190-197. Web. 28 Aug. 2014.
http://annals.org/article.aspx?articleid=1819123
53 Akinsanya-Beysolow, I. Morbidity and Mortality Weekly Report. Advisory Committee on Immunization Practices Recommended Immunization Schedule Persons
Aged 0 Through 18 Years — United States, 2014. Feb. 7, 2014 / 63(05); 108-109. Web. 28 Aug. 2014.
http://www.cdc.gov/vaccines/adults/rec-vac/pregnant/whooping-cough/protection.html
A nonprofit independent licensee of the Blue Cross Blue Shield Association
29 of 29
Fall 2014