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Concluding Observations To conclude the workshop, Dr. Fielding provided some summary observations. The workshop discussions highlighted the difficulties that the lack of stable funding creates for localities. Uncertain funding for immunization infrastructure has limited opportunities for longer term planning and commitments and therefore made it difficult for the health department to be a good partner in community immunization efforts. However, states will be receiving new funding for public health infrastructure investments as part of the federal effort to strengthen the nation’s ability to respond to bioterrorism. Officials should be considering how those funds can be used most effectively at the state and local levels. Improvements in areas such as disease surveillance and public health laboratories promise benefits for the nation’s immunization system as well. With much greater responsibility for immunization services resting with private providers and health plans, the need for consultation between the public and private sectors becomes increasingly important. Programs like Vaccines for Children (VFC) and the State Child Health Insurance Program have improved access to immunization services, but other approaches will be needed to improve immunization coverage among the children who are hardest to reach. Dr. Fielding noted that the lack of VFC eligibility for children in California’s Healthy Families Program poses financial problems for both the private providers serving those children and the state. He also expressed concern about the pros-
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pect that employers might adopt a lump-sum approach to health insurance benefits for preventive services. If employees choose not to use those benefits for appropriate immunizations, declining immunization coverage rates would increase the risk of disease outbreaks. Vaccine pricing and supply issues are looming larger. Persistent production problems for some vaccines and the decisions by manufacturers to stop producing other vaccines are reducing vaccine supplies and pushing prices up. The price increases in combination with the reductions in federal and state funding for immunization programs result in a substantial reduction in immunization-related purchasing power at the local level. Dr. Fielding also commented that immunization financing questions cannot be separated from issues related to vaccine development and production. He urged renewed examination of public policy tools (e.g., extended patent protection) that could provide added incentives for vaccine development and production. Registries are an important tool for immunization programs, but they require improved usability. The long-anticipated availability of electronic medical records systems could resolve many of the current problems of burdensome and duplicative data entry. But further work is still needed to produce effective and affordable systems. Dr. Fielding concluded with the observation that public health is often said to be invisible when it works because people are not getting sick. But the public health system has suffered from neglect because of its invisibility, and leadership is needed to ensure that immunization issues remain visible and receive appropriate attention. Dr. David Smith followed up, posing the possibility that the current problems of unstable funding, rising vaccine prices, and uncertain vaccine supplies might be creating conditions for a “perfect storm” that could result in serious disease outbreaks. Emphasizing the importance of advocacy on behalf of any of a broad range of immunization needs, he encouraged workshop participants to use the immunization system framework laid out in Calling the Shots as a basis for seeking legislative attention for these issues and for reaching out to other, less familiar partners.
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