Struggling to seal cracks in the immunization system

Vaccinations are considered to be one of the most cost-effective means of improving public health, but experts say financial gaps are straining the system.

By Victoria Stagg Elliott, amednews staff. July 23, 2001.

Public health officials talk about the measles outbreak of 1989-1991 the way some people talk about the day Kennedy was shot or Pearl Harbor was bombed. They know where they were. They remember how they felt. It was a disease that had almost been eliminated through vaccination, and then it was back -- striking 43,000 and killing 100.

"I had a warehouse full of vaccine," said Edward Mihalek, a supervisory public health adviser with the Centers for Disease Control and Prevention's immunization program who works with the Chicago Dept. of Public Health. "But kids were still dying."

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Measles is no longer endemic to the United States, according to the CDC.

But this experience with the illness is an important reminder of what can still happen. Public health officials say another outbreak of a vaccine-preventable disease may not be too far off unless the holes in the national immunization system -- gaps affecting both children and adults -- are filled.

"Cattle are better immunized than children," said David R. Smith, MD, chair of the Institute of Medicine's Committee on Immunization Finance. "And children are better immunized than adults."

Investment needed

What is needed, say experts, is more money to pay for vaccine supplies, strengthen delivery systems, fund immunization registries and educate physicians, parents and other adults about needed immunizations.

Vaccinations, particularly childhood ones, are considered among the most cost-effective preventive services, ranked alongside smoking cessation in terms of public health bang for the buck. But federal funds have been cut by more than 50% from a high point in the early 1990s, according to "Calling the Shots: Immunization Finance Policies and Practice," a report published by the Institute of Medicine last year.

"We need to spend more money," said Dr. Smith. "It's worth it. The system is underfinanced, under-resourced and falling apart."

At the same time, the vaccine schedule has become much more costly and complex.

In 1985, the childhood series of immunizations included five shots and cost less than $50. Now, the series involves as many as 24 shots and costs nearly $400. Experts say that by 2020, more than 35 vaccines may become a part of the schedule.

According to testimony by physicians and public health officials at a recent IOM hearing in Chicago, Medicare reimbursement is insufficient for adult vaccines such as the flu shot. Also, some insurance companies don't cover all the recommended childhood vaccines.

In addition to more financial investment to cover the costs of the actual shots, incentives to entice the private sector to manufacture the vaccines are also needed.

Currently, tetanus toxoids are only made by one company; the flu vaccine by three. The result is that some patients fail to get the shots they need because the supplies simply aren't there when they need them. There is now a 12- to 18-month wait for the tetanus toxoid vaccine. The flu vaccine was delayed last year, and recent reports indicate that it is again expected to be late this season.

"There are just too few companies in the biz," said Dr. Smith.

On the government side, federal funding is unpredictable, adding to the system's instability, and the cost of vaccines also varies widely according to who's buying. For example, state, local and federal agencies all buy at different rates. "Our purchasing system is very dysfunctional," said John Lumpkin, MD, MPH, director of the Illinois Dept. of Public Health.

But even if physicians have vaccine stock in their offices, and there's money to pay for it, the complicated schedule confuses most parents and some doctors. Several studies have shown that the parents of under-immunized children believed that their kids had all the recommended shots.

"Doctors want reminder cards and flow sheets," said Carol Wilhoit, MD, medical director for quality improvement with Blue Cross and Blue Shield of Illinois. "Parents just want to be told what to do because they can't keep track."

In addition, adults and children change physicians frequently, and it's easy for immunization records to be lost. People change insurance carriers. Children move in and out of Medicaid. All this means that some children end up getting over-immunized and some miss what they are supposed to get.

Some states have set up immunization registries in order to give children a continuous record even if they do change doctors.

The American Medical Association reaffirmed its support of such plans at its recent Annual Meeting in Chicago, although there is still concern about the additional paperwork required by doctors to participate.

"Access is not an issue," said Dr. Lumpkin. "Fragmentation of care is the problem."

But strengthening the system that gets vaccines to the public is vital -- not just because of the increasing number of vaccines available for children -- but also for adults.

There is an increasing number of immunizations available for adults, now and in the future, including a possible AIDS vaccine.

Adults: a systemic challenge

"Where we are with adult immunization is where we were 25 years ago with children's immunizations," said William Schaffner, MD, chair of the Dept. of Preventive Medicine with Vanderbilt University School of Medicine in Nashville, Tenn.

The flu vaccine is a case in point that public health officials use to demonstrate the difficulties involved in getting vaccines to adults. There is no means to assure the supply, no money for outreach to recipients, and prioritizing distribution is extremely challenging.

The CDC reported last month that a delay is expected again this year, and physicians are reporting that they are having problems even placing orders. When they do order, the price is double or more what was charged last year.

"The Springfield Oregon Family Practice groups could not get a price quote until April 26," said Frank Baumeister, MD, a Portland, Ore., gastroenterologist during the AMA's Annual Meeting in Chicago. "And when we did, the price was doubled."

ADDITIONAL INFORMATION:

CDC predicts flu vaccine delays

The Centers for Disease Control and Prevention announced June 21 that delays are again expected in the flu vaccine pipeline. About 53.5 million, or 64%, of needed doses will likely be delivered by the end of October.

The CDC is also warning that current predictions could be altered by unforeseen production and distribution problems, uneven distribution, early vaccination of young healthy individuals and price speculation.

In preparation for the delay, the Advisory Committee on Immunization Practices is recommending that high-risk individuals be targeted in September and October. Physicians should also continue vaccinating through December as long as vaccine is available.

Last year's season was marred by significant vaccine delays. Only 26.6 million doses were available by the end of October.

Public health officials stress that with more vaccine needed this year -- 84 million doses compared to approximately 75 million in most years -- and the vaccine only being manufactured by three companies, it may no longer be realistic to expect all the vaccine to be available at once.

Weblink

AMA's Vaccination for Adults page, with information on the 2001-02 influenza season (http://www.ama-assn.org/ama/pub/physician-resources/medical-science/vaccination-resources.shtml)

CDC's National Immunization Program (http://www.cdc.gov/nip/)

IOM report, "Calling the Shots: Immunization Finance Policies and Practices" (http://www.nap.edu/books/0309070295/html/)

Immunization Finance Workshops for the IOM report, with all the slides and audiotape from the discussion from the June 15 meeting. (http://www.iom.edu/iom/iomhome.nsf/Pages/HCS+Immunization+Finance+dissemination/)