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hepatitis B [HBV], and others yet to come). The increased costs of some of these combination products will be balanced by the eventual reduction in the number of visits required to receive immunizations.

Investments are continuing to be made in the development of vaccines that can be administered by mucosal routes (gastrointestinal or respiratory tract) obviating the need for injections. Although the oral polio virus vaccine remains the only mucosal vaccine in widespread use, licensed vaccines against typhoid and cholera, not to mention the newly licensed vaccine for rotavirus, exemplify the potential of these routes.

In the era of managed care, reimbursement for vaccines and vaccine administration follows a number of different pathways. For some families, health insurance pays. The Vaccines for Children Program provides vaccines for nearly 60% of the nation’s children. More than a dozen states provide free vaccines for all children, whatever their family’s income may be.

In an attempt to overcome the problem of inadequate record keeping, immunization registries have been initiated by a number of states and communities. The registries initially covered public health clinics but have also provided the opportunity for the participation of private providers. It is hoped that registries will help overcome the major problem of a lack of availability of up-to-date immunization records during clinic and office visits. Although concerns regarding the confidentiality of records have been raised, such problems should be amenable to solution. As quality assessment programs are instituted for managed care, the provision of immunization (and other preventive medicine measures) should become a hallmark of quality performance. This too should further ease the problem of families whose current insurance coverage does not include immunization.

Delivery of Vaccines to Adults

The primary care setting is an important site for adult immunizations. In 1992, 85% of influenza immunizations in the United States were administered by private physicians to patients who paid for the vaccine themselves (Fedson, 1995). On the whole, relatively few patients received influenza vaccine from state or local health departments. Several studies have shown that high rates of immunization occur in the office setting whenever patients are offered vaccines during office visits (ACP, 1990). In one study, patient acceptance of vaccination increased 11- to 12-fold when it was recommended by health professionals (Siegel et al., 1990).

Despite the generally favorable attitudes of physicians toward vaccines for adults and evidence that vaccines are cost-effective, major gaps in adult immunization still exist. Although rates of influenza immunization for elderly people have increased nationally, with coverage rates now above 50%, pneumococcal and HBV vaccines are underused (General Accounting Office, 1995; Williams



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