Report Calls for Investment in U.S. Immunization System.

Renewed Threat of Disease Outbreaks

The country's immunization system is weakening in spots, and the risk of disease outbreaks is increasing, says Calling the Shots: Immunization Finance Policies and Practices. According to this report from the Institute of Medicine (IOM) of the National Academies, a look past current high immunization rates reveals a system facing new responsibilities and shrinking or uncertain resources, which leave it ill-equipped to meet future needs. State and local public health agencies are not adequately prepared to deliver new vaccines, step up efforts to immunize adults with chronic health problems, or eliminate persistent disparities in vaccine coverage between low-income groups and the general population. Gaps in data collection have created blind spots. Also, the infrastructure needed to monitor the performance of private health plans is inadequate.

Each day, 11,000 children are born in the United States, all of whom require a series of vaccinations. If the system cannot keep up and immunization rates fall, the risk of vaccine-preventable disease outbreaks will increase, the report says. A vivid reminder is the measles outbreak that began in 1989 and led to 43,000 cases and 100 deaths, mainly among young children. Every year, diseases that can be prevented by vaccination kill 300 children and between 50,000 and 70,000 adults. Influenza and pneumonia account for most of the adult deaths.

National Strategy Needed

The immunization system is funded by a complex array of federal entitlements and grants, as well as by state appropriations. The IOM study, requested by the U.S. Senate Appropriations Committee, outlines a national strategy designed to help the system face growing challenges and recommends an enhanced federal and state partnership. Over the first five years, $1.5 billion should be invested--an annual increase of $175 million over current spending--to strengthen the infrastructure. Two-thirds of this funding should come from the federal government in the form of grants, with the remainder coming from state governments.

Furthermore, the system for allocating these grants should be overhauled. Currently, the Centers for Disease Control and Prevention (CDC) distributes the funding on a discretionary basis. This method should be replaced by a formula that would provide a base level of support to all states. To ensure that states with the greatest needs get an adequate share, additional support would be tied to the health demands faced by each state, its capacity to meet them, and its immunization performance. Also, each state should be required to contribute some of its own money to receive the extra support.

As new vaccines are made available and recommended by CDC for widespread use, federal and state governments will likely need additional funds to purchase vaccines for the poor and uninsured. The report urges Congress to anticipate a need for such increased funding in the near future. In the case of adults, the current amount spent to purchase vaccines is too low, and Congress should increase funding by $50 million per year. Collectively, the states ought to share the cost of expanded purchases by spending an additional $11 million to buy vaccines for adults.

The private sector also should do more, the report says. Most states allow health insurers to decide whether their plans will cover the cost of vaccines that have been recommended for widespread use. Insurers should not have that choice. Also some insurers or providers send low-income patients to public health clinics to get vaccinations that should be administered in the private-care setting.

Who's Getting Vaccinated?

To improve monitoring, federal and state agencies should develop a set of consistent measures, the report recommends. Currently, the method used by many health care insurers and providers to document how many of their patients have completed the recommended series of vaccinations excludes certain high-risk populations. For example, a number of managed care plans report immunizations only for children who have been continuously enrolled as patients for one year. This approach tends to undercount or miss children on Medicaid, who must frequently change providers as their eligibility changes or because they are reassigned to new doctors by the system itself.

If distinct pockets of low vaccination coverage remain undetected, they will provide a reservoir for future disease outbreaks, the report says. National surveys indicate that nine percent fewer poor children complete the full series of critical vaccines than do other children. Immunization rates for high-risk adults are especially low, particularly for hepatitis B, tetanus, influenza, and the bacteria that cause pneumonia.

Future Challenges

The complexity and magnitude of the task are likely to increase. The federal government continues to expand the list of vaccines recommended for widespread use, as well as the target ages for receiving vaccines. As a result, immunization costs can be expected to rise, along with the difficulty of managing the system. Some states already have had a hard time integrating new vaccines. In 1998, for example--two years after a CDC advisory panel recommended the chicken pox vaccine for children between one and 12 years of age--the national pediatric immunization rate for this vaccine was only 43 percent.

The patchwork of private health care providers and federal, state, and local government services that make up the national immunization system also add to the complexity. Public health officials are finding it increasingly difficult to monitor the effectiveness of the system. The tracking is especially difficult in the case of children who must move on and off the Medicaid rolls. Yet even as the system becomes harder to manage, federal grants supporting the immunization infrastructure have been cut by more than 50 percent. As a result, long-range data collection, assessment of immunization rates, and strategic planning efforts have all suffered. A handful of states also have cut back on some of the extra locations where children can get vaccinated, such as clinics that provide food stamps.