Vaccination news and notes

Pediatric vaccines have been much in the news recently, with new FDA approvals and the release of data on immunization coverage as of 2002 by the National Immunization Program (NIP) of the CDC. The new statistics show that the number of children being immunized is at an all-time high, with a particularly significant increase in coverage for varicella, to 80.6%, and three or more doses of pneumococcal conjugate vaccine, up to 40.9%. Coverage for the 4:3:1:3:3:1 series (four doses of diphtheria-tetanus-acellular pertussis [DTaP] vaccine, three of polio, one of measles-mumps-rubella [MMR], three of Haemophilus influenzae type b, three of hepatitis B, and one of varicella) increased from 61.3% in 2001 to 65.5% in 2002.

Is this good news? Yes and no: If roughly two thirds of children in the US have been covered for the 4:3:1:3:3:1 series (that's good), then one third are still not fully immunized (bad). Furthermore, level of coverage varies considerably state to state and by urban area. The highest estimated coverage for the recommended series was 79.3%, in Santa Clara County, Calif.; the lowest, 57.5%, in Newark, N.J.

Deficiencies in coverage are the result of a number of variables, including lack of insurance, interruption in supply, and growing indifference or outright opposition to childhood immunization in some regions:

• Data released by the Robert Wood Johnson Foundation show that 5 million children eligible for the State Children's Health Insurance Program (SCHIP) or Medicaid are nevertheless not enrolled. The foundation is bankrolling a program known as Covering Kids to connect uninsured children to these programs.

• Severe shortages of certain routinely recommended childhood vaccines have occurred in recent years and, although the shortage problem seems to have been resolved for now, experts believe it is likely to recur.

• Despite a plethora of studies refuting the allegation that either the MMR vaccine or the mercury-based vaccine preservative thimerosal causes autism (most recently, in the American Journal of Preventive Medicine, on the thimerosal connection, and in the Journal of the American Medical Association, on an observed brain growth difference in autistic children that occurs months before the age at which the MMR vaccine is administered), rumors and allegations continue to spread. Last month, the governor of Texas signed legislation that allows parents to opt out of school-entry immunization for their child on the flimsiest of grounds—and to the applause of the organized antivaccination community. Countering the backlash against immunization will require a similar degree of organized opposition by health-care professionals.

Given these constraints on full immunization coverage, the release in August of a report from the Institute of Medicine (IOM) Committee on Evaluation of Vaccine Purchase Financing was particularly timely. In "Financing Vaccines in the 21st Century: Assuring Access and Availability," the committee advocates revolutionary changes in the way vaccines are produced, distributed, and paid for, including:

• Mandated insurance coverage for recommended vaccines by all public and private insurers

• An end to government purchase of vaccines

• Government subsidies to insurers and providers, based on the societal value of a given vaccine and not simply on its market price. These subsidies, given before vaccine manufacture, will create incentives for manufacturers to continue to produce current vaccines and develop new ones.

• Changes in the procedures and membership of the Advisory Committee on Immunization Practices (ACIP), so that the committee's recommendations can associate coverage decisions with societal benefits and costs, including consideration of the impact of the price of a vaccine on ACIP's recommendations for its use. ACIP would determine the value of the subsidies offered.

• Government vouchers for uninsured children and adults to receive immunization from the provider of their choice.

• A series of stakeholder deliberations, convened by the National Vaccine Program Office, on issues associated with a shift from current government vaccine purchase programs to a system of mandates, subsidies, and vouchers.

The members of the committee envision a major national debate on these extraordinary proposals. The full text of the report can be read at www.nap.edu .