National Perspectives on the Immunization System

Discussion of national aspects of the immunization system provided a backdrop for consideration of the public health situation in Texas. Dr. Smith noted that immunization has substantially reduced rates of illness from infectious diseases (Table 1). As the measles epidemic from 1989 to 1991 demonstrated, however, some vaccine-preventable diseases remain a threat if rates of immunization coverage are low. Despite improvements made during the 1990s, national immunization coverage rates for 2-year-olds and adults aged 65 years and older have not yet reached the current public health sector objective of 90 percent. Dr. Smith pointed to even lower immunization rates for adults ages 18 to 64, with only 26 percent of this group having received a vaccination against influenza in the previous year. Immunization levels are also persistently lower among low-income children and adults. For example, a study in Indianapolis and the surrounding county found that 53 percent of poor 2-year-olds had up-to-date immunizations, whereas the NIS estimate for the county as a whole was 78 percent (Bates and Wolinsky, 1998). Nationally, a 9-percentage-point disparity in immunization rates exists between children in households with incomes below the poverty level and children in higher-income households.

Dr. Rodewald reviewed key features of federal financial support through the Section 317 program and VFC for the immunization system. Under the Section 317 program, each state and territory and five large urban areas receive annual grants for the purchase of vaccines and funding for the infrastructure that supports the operation of immunization



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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop National Perspectives on the Immunization System Discussion of national aspects of the immunization system provided a backdrop for consideration of the public health situation in Texas. Dr. Smith noted that immunization has substantially reduced rates of illness from infectious diseases (Table 1). As the measles epidemic from 1989 to 1991 demonstrated, however, some vaccine-preventable diseases remain a threat if rates of immunization coverage are low. Despite improvements made during the 1990s, national immunization coverage rates for 2-year-olds and adults aged 65 years and older have not yet reached the current public health sector objective of 90 percent. Dr. Smith pointed to even lower immunization rates for adults ages 18 to 64, with only 26 percent of this group having received a vaccination against influenza in the previous year. Immunization levels are also persistently lower among low-income children and adults. For example, a study in Indianapolis and the surrounding county found that 53 percent of poor 2-year-olds had up-to-date immunizations, whereas the NIS estimate for the county as a whole was 78 percent (Bates and Wolinsky, 1998). Nationally, a 9-percentage-point disparity in immunization rates exists between children in households with incomes below the poverty level and children in higher-income households. Dr. Rodewald reviewed key features of federal financial support through the Section 317 program and VFC for the immunization system. Under the Section 317 program, each state and territory and five large urban areas receive annual grants for the purchase of vaccines and funding for the infrastructure that supports the operation of immunization

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop TABLE 1 Change in Annual Morbidity from Vaccine-Preventable Diseases: Prevaccine Baseline and 2000 Disease or Organism Prevaccine Baseline Date Average No. of Annual Baseline Cases No. of Cases in 2000 % Decrease Diphtheria 1920–1922 175,885 1 100.00 Haemophilus influenzae, type b and unknown (< 5 years) 1985 20,000 167 99.20 Measles 1958–1962 503,282 86 99.98 Mumps 1968 152,209 338 99.80 Pertussis 1922–1925 147,271 7,867 95.00 Poliomyelitis 1951–1954 16,316 0 100.00 Rubella 1966–1968 47,745 176 99.60   SOURCE: Adapted from CDC (2002). program activities. The Section 317 program awards are the major source of federal support for essential activities of the immunization system such as surveillance for rates of vaccine coverage and efforts to improve coverage. For the 2001 grant year, CDC awarded $176.1 million for immunization program operations and $175.6 million for vaccine purchase. VFC, a federal entitlement program, funds the purchase of vaccines for use by participating health care providers to serve eligible children. CDC estimates that more than 40,000 private providers are participating in VFC. These providers vaccinate about 90 percent of all preschool-age children, using vaccines purchased with funds from a combination of sources from the private and public sectors. Most states use Section 317 program funds to obtain additional doses of vaccines that are recommended for preschool-age children but that are not covered by VFC. The Section 317 program also allows for the purchase of some vaccines for adolescents and adults, but use of Section 317 program funds for this purpose is limited. Federal contracts with vaccine manufacturers make it possible for states to obtain discounted prices for vaccines under the Section 317 program and VFC. Some states also use state funds to purchase additional vaccines at these contract prices. More than half of all vaccines are purchased under these federal contracts: 36 percent through VFC and 15 percent through the Section 317 program. Under the federal contract, the current cost of the vaccines recommended for complete immunization of preschool-age children is nearly $400 per child, almost half of which is accounted for by the recent addition of four doses of the pneumococcal

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop conjugate vaccine. The increased cost of recommended vaccines has significant budgetary implications, and Dr. Rodewald noted the need for better tools to estimate annual vaccine requirements. In addition, vaccine shortages (e.g., the influenza vaccine and the diphtheria and tetanus toxoids and activated pertussis vaccine [DTaP]) pose problems of ensuring equitable allocation and appropriate targeting of available vaccine supplies. For the immunization infrastructure component of the Section 317 program, CDC is encouraging grantees to pursue evidence-based strategies for improving immunization rates. Recommendations from the Task Force on Community Preventive Services (2000) include, among others, reducing out-of-pocket costs to families, implementing reminder/recall systems to notify families that a child is due or past due for vaccination, and giving providers feedback from assessments of rates of immunization coverage among their patients. OVERVIEW OF STATE CONCERNS Gary Freed, of the University of Michigan, reviewed the findings from a series of interviews with immunization program officials in all 50 states. Conducted as part of the data collection effort for Calling the Shots (IOM, 2000), these interviews helped document features of state immunization programs and state responses to changes in federal immunization policies and funding for vaccines and immunization programs. For vaccine purchase, Dr. Freed and colleagues found that states relied heavily on federal funding, with 11 states allocating no additional state funds for this purpose. In 21 states, including Texas, between 2 and 10 percent of the funding for publicly purchased vaccines came from state funds. The remaining states provided larger amounts of funding. State officials cited several factors that had placed new demands on budgets for vaccine purchase during the 1990s, including the addition of new and more expensive vaccines to the recommended schedule of immunizations, delays in VFC coverage of and federal contracts for new vaccines, and demand for vaccines not included in VFC. In Texas, for example, the hepatitis A vaccine is recommended for some children but it is not a vaccine included in VFC. State officials also reported pressure from health care providers to supply publicly purchased vaccine for children who are not eligible for VFC. In addition, they felt that the Advisory Committee on Immunization Practices (ACIP) failed to give adequate consideration to the financial impact of its recommendations to add vaccines to the immunization schedule and, therefore, to the set of vaccines for which children were eligible under public programs.

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Setting the Course: A Strategic Vision for Immunization, Part 2 Summary of the Austin Workshop Dr. Freed noted that variations in the levels of state investments in immunization program operations and infrastructure exist, with these variations reflecting factors such as the state’s child population and the state’s organization of immunization services. Overall, Dr. Freed noted, about half of the states provide no funding for immunization infrastructure. States that fund public clinics for the delivery of immunization services may require larger budgets for immunization infrastructure than states that primarily rely on private providers. Immunization programs in some states also benefit from in-kind support provided by other state agencies, such as the education department if school personnel are responsible for assessing the immunization status of children entering school. State officials reported seeing CDC as a key partner in immunization activities. State priorities, however, were not necessarily consistent with those established by CDC in conjunction with Section 317 program grants for the immunization infrastructure. In rural states, for example, CDC’s emphasis on “pockets of need”—areas with especially low immunization rates, often in inner cities—is less relevant. Because states rely heavily on CDC funding for their immunization infrastructure support, the influx of funding in the early 1990s was welcome, but subsequent reductions have forced states to reevaluate their program priorities and often to reduce services. Some states, for example, have had to reduce staff and operating hours at immunization clinics or reduce efforts to support connections with Special Supplemental Food Program for Women, Infants, and Children (WIC) clinics. Section 317 program funding for immunization program infrastructure was reduced in the mid-1990s in part because many states were not able to spend their grants in a timely fashion. The interviews with state immunization program officials revealed that various administrative obstacles had contributed to this problem. On the federal side, the program required that grant funds be used within the grant year, but awards were often delayed and the federal government could give no assurances regarding future funding. Without assurances of stable and sustained funding, states were frequently reluctant about or even prohibited from hiring new staff or undertaking multiyear projects, such as immunization registry development. In states like Texas with a 2-year legislative and budget cycle, immunization programs had no way to adjust their budgets to make use of the additional funding. Dr. Freed also observed that term limits for state legislators pose a challenge for immunization programs. New legislators may be uninformed about immunization issues. Furthermore, it can be difficult for legislators to see either the positive or the negative effects of funding decisions during their time in office because it may take two or three legislative sessions for the effects to become evident.