Category Archives: Vaccines
CDC: 60 Percent of Diners Will Use Menu Calorie Counts When Available
Approximately 6 in 10 U.S. adults will choose their restaurant meals in part because of menu label information when it’s available, according to the U.S. Centers for Disease Control and Prevention’s (CDC) latest Morbidity and Mortality Report. Researchers analyzed the self-reported usage of 118,013 adults in 17 states in 2012 to determine that about 57 percent will look to the provided calorie information. New York had the highest rate, with 61.3 percent, while Montana had the lowest, at 48.7 percent. Federal law requires calorie information be provided by any restaurant with 20 or more locations; while the regulations are not yet final, many establishments already voluntarily provide menu labeling, according to the CDC. Read more on nutrition.
Depression, Stress, Hostility Tied to Higher Stroke Risk
Depression, stress and hostility may be linked to a higher risk for stroke, according to a new study in the journal Stroke. Using information provided by approximately 7,000 adults who did not have heart disease or a history of stroke at the beginning of the study, researchers followed up nearly nine years later and determined that depression was associated with an 86 percent increased chance of a stroke or a transient ischemic attack, stress was associated with a 59 percent increase and hostility doubled the risk. “[C]hronic stress and negative emotions are important psychological factors that affect one's health, and findings from this study link these factors to brain health in particular," said the study's lead author, Susan Everson-Rose, an associate professor of medicine at the University of Minnesota, according to HealthDay. "Patients and their health care providers should be aware that experiences of chronic stress and negative emotional states can increase risk for stroke.” Read more on heart health.
Washington State Sees Most Measles Cases Since 1996
A slight decline in Washington State’s mumps and rubella vaccination rate has coincided with the state’s highest number of measles case in 18 years, according to officials. Washington has reported 27 cases so far this year and is currently in the midst of its third outbreak. While homegrown measles was declared officially eliminated from the United States in 2000, infections from people who have travelled overseas remain a threat. There were 554 total cases of measles and 17 outbreaks reported in the United States between Jan. 1 and July 3 of this year. Read more on infectious diseases.
FDA: Sunlamps to Require Health Warnings
The U.S. Food and Drug Administration (FDA) has issued a final order that requires sunlamp products and ultraviolent (UV) lamps for use in sunlamp products to carry warnings stating that they should not be used by people under the age of 18. The order reclassifies the products from low-risk (class I) to moderate-risk (II). “The FDA has taken an important step today to address the risk to public health from sunlamp products,” said Jeffrey Shuren, MD, director of the FDA’s Center for Devices and Radiological Health, in a release. “Repeated UV exposure from sunlamp products poses a risk of skin cancer for all users—but the highest risk for skin cancer is in young persons under the age of 18 and people with a family history of skin cancer.” People who are exposed to UV radiation as a result of indoor tanning increase their risk of melanoma by 59 percent, according to the American Academy of Dermatology. Read more on cancer.
CDC: U.S. Measles Cases at a 20-year High
Cases of measles in the United States are at a 20-year high, with international travel by unvaccinated people a major contributor, according to the U.S. Centers for Disease Control and Prevention (CDC). The CDC reports that there were 288 U.S. cases between January 1 and May 23 this year—and 97 percent were associated with importation by travelers from at least 18 countries. Approximately 90 percent of the cases were in people who were not vaccinated or whose vaccination status was unknown. “The current increase in measles cases is being driven by unvaccinated people, primarily U.S. residents, who got measles in other countries, brought the virus back to the United States and spread to others in communities where many people are not vaccinated,” said Anne Schuchat, MD, assistant surgeon general and director of CDC’s National Center for Immunizations and Respiratory Diseases, in a release. “Many of the clusters in the U.S. began following travel to the Philippines where a large outbreak has been occurring since October 2013.” Read more on vaccines.
Type of Increased Heart Risk Depends on Which Blood Pressure Number is High
The type of increased heart risk a person with high blood pressure faces depends on which number in their blood pressure—the top, which is systolic, or the bottom, which is diastolic—is high, according to a new study in The Lancet. Researchers analyzed health care date on more than 1 million people ages 30 and older in England, finding that people with higher systolic blood pressure had a greater risk of bleeding strokes and stable angina, while people with higher diastolic blood pressure were more likely to be diagnosed with an abdominal aortic aneurysm. In addition, they found that a 30-year-old with high blood pressure has a 63 percent lifetime risk of developing heart disease, compared with 46 percent for a person with normal blood pressure. "With lifetime risks this high, the need for new blood pressure-lowering strategies is paramount," said lead investigator Eleni Rapsomaniki, MD, from The Farr Institute for Health Informatics Research in London, England, in release. Read more on heart health.
New NCHH, APHA Standards to Improve U.S. Housing Health
A new report from the National Center for Healthy Housing (NCHH) and the American Public Health Association (APHA) establishes new standards to help improve housing for all Americans. The new National Healthy Housing Standard outlines a health-focused property maintenance policy for the nation’s 100 million existing homes—single family, multifamily, rental and owner occupied. Approximately 40 percent of metropolitan homes have one or more health and safety hazards, according to the NCHH, while the American Housing Survey determined that approximately 6.3 million housing units are considered to be substandard. “While we have made great strides in improving the quality of housing nationwide, too many Americans are left making the false choice between affordable or quality housing. Families deserve access to quality and affordable housing that allows them to put down roots in a community, build wealth, put kids through college and start businesses,” said U.S. Department of Housing and Urban Development Secretary Shaun Donovan, in a release. Read more on housing.
Red Cross Campaign Will Work to Cut Drowning in Half in 50 U.S. Cities
As part of its celebration of 100 years of swimming safety education, the Red Cross is launching a new national campaign to reduce the drowning rate by 50 percent in 50 U.S. cities. The 3-5 year campaign will target 50,000 people across 19 states. A new survey from the organization’s drowning prevention campaign found that while 80 percent of Americans said they could swim, only about 56 percent of those people exhibited “water competency”—meaning that they could perform these five critical water safety skills:
- Step or jump into the water over your head
- Return to the surface and float or tread water for one minute
- Turn around in a full circle and find an exit
- Swim 25 yards to the exit
- Exit from the water
“We're asking every family to make sure that both adults and children can swim and that parents make water safety a priority this summer,” said Connie Harvey, director of the Red Cross Centennial Initiative. Read more on injury prevention.
CDC Releases Vaccine Schedule App for Clinicians, Health Care Professionals
The U.S. Centers for Disease Control and Prevention (CDC) has launched a new app that provides clinicians and other health care professionals access to the CDC’s latest recommended immunization schedules. The CDC Vaccine Schedules app replicates the appearance of the printed schedules that are reviewed and published each year, and includes information such as the correct vaccine and dosage. The schedules include:
- Child and adolescent schedules with immunization recommendations from birth through age 18
- Catch-up schedule for children 4 months through 18 years
- Adult schedule, including recommended vaccines for adults by age group and by medical condition
- Contraindications and precautions table, with all footnotes that apply to schedules
The app is available in the iTunes App Store and will be released for Android devices in a few months. Read more on vaccines.
CDC Confirms First U.S. Case of MERS Virus
The U.S. Centers for Disease Control and Prevention (CDC) has confirmed the first U.S. case of MERS, a respiratory virus first identified in the Middle East two years ago. The virus was diagnosed in a U.S. patient who recently traveled from Saudi Arabia. The patient is being treated at a hospital in Indiana and people who traveled with the patient on an airplane from the Middle East are being contacted and told to see a doctor if respiratory symptoms develop. In some Middle Eastern countries, the virus has spread from person to person through close contact, but the CDC says there is no evidence of the sustained spread of the virus in general settings. "The virus has not shown the ability to spread easily in a community setting," said Ann Schuchat, MD, director of CDC's National Center for Immunization and Respiratory Diseases, during a telephone press conference on Friday.
"In this interconnected world we live in, we expected MERS to make its way to the United States....We have been preparing since 2012 for this possibility,” said Tom Frieden, MD, director of the CDC in a statement.
The CDC says that anyone who experiences respiratory illness within 12 weeks of traveling to Saudi Arabia, or becomes ill after contact with someone who recently traveled to Saudi Arabia, should contact their doctor. The CDC has not recommended that anyone change their travel plans based on the MERS virus. So far there have been 401 confirmed cases of the MERS virus in twelve countries, including the United States; 93 people have died of the virus. Camels have been identified as carriers of MERS, but it's not known how the virus is being spread to people. Read more on infectious disease.
WHO: World Polio Threat an ‘Extraordinary Event’ That Requires a Coordinated International Response
Despite the near cessation of the international spread of wild polio virus in the low transmission seasons (January to April) from January 2012 through 2013, a new report from the World Health Organization (WHO) finds that the current international spread of polio can now be considered an “extraordinary event.” WHO experts say the public health risk—the WHO Emergency Committee unanimously agreed that the conditions for a Public Health Emergency of International Concern (PHEIC) have been met—requires a coordinated international response. So far in 2014 there has already been international spread of wild polio virus from 3 of the 10 States that are currently infected: in central Asia (from Pakistan to Afghanistan), in the Middle East (Syrian Arab Republic to Iraq) and in Central Africa (Cameroon to Equatorial Guinea). Pakistan, Cameroon and the Syrian Arab Republic pose the greatest risk in 2014, according to the WHO. Read more on global health.
Study: Even Outbreaks May Not Change the Minds of Parents Opposing Childhood Vaccines
Parents who choose not to have their children receive mandatory immunizations may not change their minds even in the face of outbreaks of childhood illnesses, according to a new study. Researchers studied a pertussis outbreak in Washington State from October 2011 through December 2012, finding “no significant increase” in the vaccination rates of approximately 80,000 infants ages 3 to 8 months, according to HealthDay. Paul Offit, MD, chief of the division of infectious diseases at the Children's Hospital of Philadelphia, said parents using “personal belief” exemptions to not have their children vaccinate is likely beyond the resurgence of diseases that were once all but eradicated in the United States. "The problem is not theoretical,” he said. "You are starting to see eroding of herd immunity with outbreaks of measles and pertussis. The main reason is people are choosing not to vaccinate their children. It's becoming a more dangerous world from the standpoint of infectious diseases. Measles and pertussis are back. These are serious diseases that before vaccine caused a lot of death.” Offit was not a part of the recent study. Read more on vaccines.
Recently, we’ve been pleased to see increased engagement across a number of posts on NewPublicHealth, particularly from public health students. Reader comments have pointed a justly critical eye toward the way studies are often interpreted and presented. This level of conversation is critical to informing and bolstering NewPublicHealth’s coverage of public health news and issues.
We have compiled a handful of reader comments below, in an effort to continue the discussion.
- Readers shared their opinions on a survey showing that Hispanic adults are not confident in their understanding of insurance terms:
- “Although the concern of this study was the disparity between white literacy and non-white literacy, general focus should be placed on understanding for people in all racial categories. A lack of health literacy leads to many issues in health care, often resulting in ineffectiveness of care.” — Jessica H.
- “The study regarding the lack of understanding of key insurance terms is interesting because while it specifically shows low-literacy levels in Hispanics, it points to a larger problem in America. Relative to this study, literacy levels were highest in Whites and lowest in Hispanics. Overall, the literacy levels were universally low. This is a problem because being unable to understand insurance terms would lead to less effective use of the insurance, or no insurance at all.” — Michael
- Readers also questioned the validity of a study that found many parents support flu shots at school, based on concerns regarding data collection methods and information presentation biases:
- “Regarding the study that found that many parents support flu shots at school: The survey used in this study was given in English, but it was found that people most likely to agree to have their children vaccinated in a school setting included parents of uninsured children...If children are not insured, it usually means the parents are not insured and have jobs that do not provide health benefits. Immigrants usually work these kinds of jobs, and probably do not speak English well. So, if the survey was only given in English, this could influence the results of the study...” — Brittany
- “Surveys aren’t the best method of collecting data. Secondly, the convenience portion, which includes vaccine beliefs and or skipping past vaccines greatly contributed to the unwillingness to consent...And this would create a high stated consent rate, due to parental preferences based on location...Lastly, although the author wrote this study with intentions of public health official’s consideration to this topic I would be concerned since this study is the first to provide this information and does however contain many biases.” — Cora Neville
- “The article mentions that only parents who answered with a yes or not sure were asked follow up questions. If a parent answered no, was there a question that asked why they would not consent?...I think collecting data on those who declined the school-located vaccination would help future researchers find a way to get those parents who originally declined to consent.” — Shannen Mincey
- Many people in the public health field have publicly weighed in on the U.S. Food and Drug Administration’s proposed changes to food labels, including NewPublicHealth readers:
- I think some parts of this new regulation will be good for consumers while others will simply be a futile effort to help consumers eat better. For example, I believe adding “added sugars” to the label will be effective in identifying the bad sugar...One change that could be helpful for consumers would be to identify the types of fiber. Although the label includes total dietary fiber, this can be misleading to consumers who may not realize they are not getting nutritional value out of all of it.” — Jessica H.
- “Food labels need to be more understandable and consumer friendly. The Healthy People Campaign and health advocates, such as Michelle Obama want America to take responsibility for their health, yet the consumers have to dissect every food label to get a proper gauge of the nature of the food they’re consuming... On the same token, I think it is going to take a great deal of further research to determine what would be considered “better align[ed] with how much people really eat.’” — Vanessa Moses
Thank you to all our readers who have made their opinions known. Let’s keep these conversations going!
FEMA Issues Advisories as Severe Weather Hits Parts of the U.S.
The Federal Emergency Management Agency (FEMA) has begun issuing advisories for states across the Southern United States expected to be impacted by severe weather.
According to the National Weather Service, a major winter storm is impacting the South and Southeast ahead of moving up the Eastern Seaboard on Wednesday.
FEMA is encouraging both residents and visitors in the track of the storms to follow the instructions of state, local and tribal officials, and monitor NOAA Weather Radio and their local news for updates and directions provided by local officials. Residents can find trusted sources for weather and preparedness information via Twitter on FEMA’s social hub.
Weather Emergency Alerts (WEA) are currently being sent directly to many cell phones on participating wireless carrier networks. These alerts are sent by public safety offices such as the National Weather Service about imminent threats like severe weather. They look like a text message and show the type and time of the alert, any action you should take and the agency issuing the alert. Check your cellular carrier to determine if your phone or wireless device is WEA-enabled. Read more on preparedness.
Dozens of Bills Introduced in Recent Years to Increase School Vaccine Exemptions
From 2009 to 2012, 36 bills were introduced in 18 states to change school immunization mandates, with the majority aimed at expanding exemptions, according to a recent review in JAMA by researchers from Emory University. None of the bills passed, but the researchers say continued efforts to change state vaccine rules are concerning. Among 36 bills introduced, 15 contained no administrative requirements, seven bills had one or two administrative requirements, and the remaining 14 contained between up to five administrative requirements in order for parents to exempt their children from school vaccine rules in a given state.
"Exemptions to school immunization requirements continue to be an issue for discussion and debate in many state legislatures," according to the study authors. Read more on vaccines.
Being in a Good Mood Can Lead to Safer Sex
HIV-positive men are more likely to have save sex when their mood improves, according to a new study by researchers at the Mailman School of Public Health at Columbia University. The study, published in the journal Psychology, included 106 sexually active, HIV-positive men who have sex with men who completed weekly surveys over six weeks that asked about their sexual behavior, depression, and wellbeing during the prior week. Overall, 66 percent of study participants reported having unprotected intercourse in the prior two months; 81 percent had multiple partners. Three-quarters of the study participants were black and Latino men, a group disproportionately affected by HIV.
The researchers found that the men who reported an increase in their wellbeing in a given week were more likely to have safe sex (66%), while those who reported higher-than-usual levels of depression were more likely to engage in the risk behaviors (69%). The researchers are now studying potential interventions that might help address risky behaviors during depressive phases. Read more on sexual health.
Picture this: The world just ended. Well, not completely. But things aren’t looking up. An influenza strain has cut a deadly swath through nearly every continent. Or maybe the Black Death is making a special encore appearance. Or your now-undead neighbor—Phil, normally a great guy, invited you to a dinner party just last week—is shuffling around the front yard, trying to gnaw on your brains.
The point is it’s time for action. And since we’re talking theoretical, we might as well be talking fictional, too. Below is NewPublicHealth’s “Outbreak Dream Team”—pop culture characters with the diverse skills we’d need to respond to and cure a deadly epidemic. And maybe a dose of what’s really needed in the way of a public health workforce to keep us ready for whatever could happen next.
- In a nationwide (or global) public health emergency such as a pandemic, the President has to step up and provide leadership among different sectors and divisions of the government to coordinate a response and assure the nation of a secure path forward.
Laura Roslin, “Battlestar Galactica”
As a former Secretary of Education she has experience working with large groups with disparate goals. (Plus, she gets that education impacts health in so many ways). And as president of the roughly 50,000 humans left alive after a Cylon invasion wiped nearly everyone out, she’s adept at balancing public policy needs, working with everyone from public advocates to top military leaders. Some of her decisions are more-than-a-bit iffy, but you try pleasing everyone all the time when the last vestiges of humanity are spread across a fleet of ships drifting through space.
National Public Health Lead
- Equivalent to the Director of the U.S. Centers for Disease Control and Prevention (CDC). The CDC safeguards the nation’s health by preparing for, detecting, rapidly responding to and preventing health threats 24/7 to save lives and protect communities. The director’s job is to make sure that happens.
Ann Perkins, “Parks & Recreation”
As a practicing public health nurse and the PR Director of Pawnee's Health Department, Ann Perkins has dealt with infectious disease control from a hospital, a government and even a girlfriend perspective. Smart and determined, this go-getter can not only treat the symptoms of infectious diseases, she can detect and track them, coordinate response, and educate the community—all while maintaining a confident, calm and collected public face. While Leslie Knope leads the town through the city council, Ann has the potential to lead diverse teams and bridge health and health care to coordinate a swift and decisive response. If she can take on Pawnee's obesity epidemic one candy company at a time and teach sex ed to senior citizens, she can certainly handle a national outbreak or two. Plus, she gets bonus points for being (probably) the only true public health character on television.
While it has been decades since polio was a critical threat for much of the developed world, the disease—a virus that can spread from person to person and affect the brain and spinal cord with the potential for paralysis—still causes disease and death in the developing world. Earlier this year cases were reported in Syria, while in Israel the polio virus was found in soil likely from human waste infected with the disease, prompting a revaccination campaign among children age 5 and under. Polio has continued to spread in Afghanistan, Nigeria and Pakistan, and has been reintroduced and continues to spread in Chad and in the Horn of Africa after the spread of the virus was previously stopped. Other countries have seen small numbers of cases recently after no cases for decades.
Because even a small spread of the disease could reach the United States if infected individuals carry the virus here, the U.S. Centers for Disease Control and Prevention (CDC) several years ago made polio one focus of their Emergency Operations Center. CDC staff work with the World Health Organization and foreign health departments on vaccination campaigns aimed at fully eradicating the disease.
>>Bonus Content: View the CDC's infographic, "The Time to Eradicate Polio is Now."
NewPublicHealth spoke recently with Sona Bari, senior communications officer at the World Health Organization about the efforts underway to eradicate polio globally.
NPH: How are you able to detect polio outbreaks?
Sona Bari: We have a global surveillance system for polio and know from it that since 1988 the reduction of the disease has been over 99 percent. Polio is now endemic, which means indigenous polio virus transmission has never been stopped in parts of three countries: Nigeria, Afghanistan and Pakistan. So the surveillance is important because you can get polio down to very low levels like you do now, but it can reemerge. To completely eradicate polio you have to have an effective intervention, which is largely by vaccination. And you can be bring polio under very tight control by massive vaccination, but the virus is very good at finding children who are unvaccinated or under-vaccinated, and in Nigeria, Afghanistan and Pakistan we still have large groups of unvaccinated children. So the reason that polio transmission has not been stopped in these areas is that not enough children are vaccinated.
NPH: Why is there insufficient vaccination in those countries?
Bari: The basic reason is the quality of vaccination activities. Do these countries have decent health systems—strong routine immunization systems where children are regularly taken to a medical facility for their immunizations? When there are mass vaccination campaigns, are we reaching all children? Then there are, on top of that, layers of political complexities. In one part of Pakistan, for example, there is a ban on polio vaccinations by the local warlords. So there are access and security issues, layered on top of the difficultly of reaching all who need vaccines in countries such as Nigeria or Pakistan. That said, we know that these circumstances are not unique. They may differ from country to country, and each country does have a unique combination of the obstacles, but polio has been eradicated in countries that are far poorer than Nigeria or Pakistan, that have had worse conflict and that have perhaps much worse health systems. So it can be done.
Youth Smoking Rates Reach Record Lows in 2013
Overall youth smoking declined significantly in 2013, and smoking rates fell to record lows for all three grades surveyed (grades 8, 10 and 12), according to the Monitoring the Future survey released annually by the National Institute on Drug Abuse and conducted by researchers at the University of Michigan’s Institute for Social Research. For all three grades combined, the percentage of students who reported smoking cigarettes in the past month fell from 10.6 percent in 2012 to 9.6 percent in 2013. The data is based on annual surveys of 40,000 to 50,000 students in about 400 different secondary schools. Read more on tobacco.
WHO and UNICEF Vaccinating Millions of Children in the Middle East Against Polio
The World Health Organization (WHO) and UNICEF are mounting the largest-ever immunization response in the Middle East, with a goal of vaccinating more than 23 million children against polio in Syria and neighboring countries over the next few weeks. The campaign is in response to an outbreak of polio in Syria, where 17 cases have so far been confirmed, and to the detection of the virus in sewage in other parts of the Middle East.
The campaign plans to vaccinate all children under age 5 in the targeted areas in the next few months, whether they are living at home or displaced by conflict. The vaccinations will be given at set sites or by workers going house to house, and the campaign will be carried out by national and local health authorities supported by UNICEF, WHO, the Syrian Arab Red Crescent and other partners. The total cost to UNICEF and WHO through April 2014 will be $39 million.
Prior to this outbreak, no polio cases have been recorded in Syria since 1999. The risk of spread to countries in the region and beyond is considered high, and health authorities from 21 countries have declared a public health emergency. Genetically-related polioviruses, which originated in Pakistan, were found in sewage samples in Egypt in December 2012 and in Israel in the West Bank and Gaza earlier in 2013. According to WHO, immunization activities have been significantly constrained in Syria in the past few months by the ongoing conflict, which has led to 500,000 to 700,000 children missing vaccinations.
Editor’s Note: NewPublicHealth also spoke with Sona Bari, WHO's senior communications officer, about the efforts underway to eradicate polio globally. The interview will run later today.
Read more on global health.
CDC Expects TB Test Shortage to Ease
Supplies of tuberculin skin tests are expected to return to normal in January, following shortages that health providers have been experiencing since 2012, according to the U.S. Centers for Disease Control and Prevention (CDC). Two tests are approved by the U.S. Food and Drug Administration to detect tuberculosis and diagnose active illness: Tubersol, made by Sanofi Pasteur Limited; and Aplisol, produced by JHP Pharmaceuticals, LLC. Shortages were first reported for Tubersol, which was out of production from late 2012 through April 2013, increasing the demand for Aplisol. In August, a CDC survey found 29 of 52 U.S. jurisdictions were reporting a shortage of at least one of the tests. Read more on the Centers for Disease Control and Prevention.
Epidemic of E. coli Infections Traced to One Strain of Bacteria
In the past decade, a single strain of E. coli, has become the main cause of bacterial infections in women and the elderly by invading the bladder and kidneys, according to a study published in the American Society for Microbiology's journal mBio. Besides becoming more resistant to antibiotics, the H30-Rx strain gained an unprecedented ability to spread from the urinary tract to the blood, leading to sepsis and posing a threat to the more than 10 million Americans who annually suffer from urinary tract infections. The study authors say the new findings could help trace the history of the “superbug” and possibly lead to the development of a vaccine. Read more on infectious disease.
A new study published recently in the American Journal of Public Health finds that non-medical exemption laws for vaccines required for school or daycare admission have significantly impacted the vaccination rates of at least one disease. The researchers reviewed relevant laws and regulations for each year between 2001 and 2008 and rated them on their restrictiveness in granting exemptions. The study was funded by a grant from the Public Health Law Research program, a national program of the Robert Wood Johnson Foundation.
According to the study, state laws that make it difficult for children to be exempted from vaccines on religious or philosophical grounds could reduce the number of whooping cough cases, but did not have an impact on cases of measles, mumps, haemophilus influenza type B (Hib) or Hepatitis B.
“Our research shows that during the study period, if all states increased the restrictiveness of their non-medical exemption laws by one level, the number of U.S. whooping cough cases would decline by 1.14 percent, resulting in 171 fewer cases per year,” according to study author Y. Tony Yang, ScD, MPH, associate professor at the College of Health and Human Services at George Mason University.
The study found that the impact on whooping cough may be greater than for the other diseases studied simply because whooping cough affects more people. Researchers call this a “threshold effect,” which means laws may not have a significant impact unless they works to prevent a disease that affects a critical mass of people. During the study period, whooping cough was much more prevalent than the four other diseases studied—the average incidence rate for whooping cough was 18 per 100,000 individuals from 2001 to 2008. For Hib, Hepatitis B, measles, and mumps, the mean incidence rates were less than 1 per 100,000.