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.