Date: June 15, 2000
Contacts: Neil Tickner, Media Relations Officer
Kathi McMullin, Media Relations Assistant
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Nation's Immunization Program Must Be Revitalized
To Maintain Strength and Prevent Future Disease Outbreaks

WASHINGTON -- Despite record levels of vaccination in the United States, the country's immunization system is weakening in spots, increasing the risk of disease outbreaks, says a new report from the Institute of Medicine (IOM) of the National Academies. It recommends an overhaul of the way the system is financed, including an investment of more than $1.5 billion over five years by federal and state governments -- an annual increase of $175 million over current spending. The money is needed to shore up the system's critical infrastructure and to better integrate public and private vaccination efforts.

"The system is still strong, but it is beginning to show signs of strain, and such warnings are too risky to ignore," said Bernard Guyer, chair of the committee that wrote the report, and chair, department of population and family health sciences, Johns Hopkins University School of Hygiene and Public Health, Baltimore. "We especially need to improve monitoring and outreach so the system can detect and respond when particular groups do not get the vaccines they need."

A look past the high immunization rates reveals a system facing new responsibilities and shrinking or uncertain resources, which leave it ill-equipped to meet future needs, the report says. State and local public health agencies are not adequately prepared to deliver new vaccines, step up efforts to immunize adults with chronic health problems, or eliminate persistent disparities in vaccine coverage between low-income groups and the general population. Gaps in data collection have created blind spots, leaving the system unable to assess and improve coverage rates. Also, the infrastructure needed to monitor the performance of private health plans is inadequate.

Each day 11,000 children are born in the United States, all of who require a series of vaccinations. If the system cannot keep up and immunization rates fall, the risk of vaccine-preventable disease outbreaks will increase, the report says. A vivid reminder of this is the measles outbreak that began in 1989 and led to 43,000 cases and 100 deaths, mainly among young children. Every year diseases that can be prevented by vaccination kill 300 children and between 50,000 and 70,000 adults. Influenza and pneumonia account for most of these adult deaths.

National Strategy Needed

The immunization system is funded by a complex array of federal entitlements and grants, as well as state appropriations. The IOM study, requested by the U.S. Senate Appropriations Committee, outlines a national strategy designed to help the system face growing challenges. To pay for this, the report recommends an enhanced federal and state partnership. As a start, $1.5 billion should be invested over the first five years -- an annual increase of $175 million over current spending -- to strengthen the public health infrastructure needed to manage the immunization system. Two-thirds of this infrastructure funding should come from the federal government in the form of grants, with the remainder coming from state governments.

Further, the system for allocating these grants should be overhauled. Currently, the Centers for Disease Control and Prevention (CDC) distributes the funding on a discretionary basis. This method should be replaced by a formula that would provide a base level of support to all states. To ensure that states with the greatest needs get an adequate share, additional support would be tied to the health demands faced by each state, its capacity to meet them, and its immunization performance, the committee recommended. Also, each state should be required to contribute some of its own money in order to receive this extra support.

As new vaccines are made available and recommended by the CDC for widespread use, federal and state governments will likely need additional funds to purchase vaccines for the poor and uninsured. The report urges Congress to anticipate a need for such increased funding in the near future. In the case of adults, the current amount spent to purchase vaccines is too low, and Congress should increase funding by $50 million per year. Collectively, the states ought to share in the costs of expanded purchases by spending an additional $11 million to buy vaccines for adults.

In addition to public investments in the system, the private sector should do more, the report says. Most states allow health insurers to decide whether their plans will cover the cost of vaccines that have been recommended for widespread use. Insurers should not have that choice, the committee said. Also, some insurers or providers send low-income patients to public health clinics to get vaccinations that could and should be administered in the private care setting.

Who's Getting Vaccinated?

To improve monitoring of immunization levels, federal and state agencies should develop a set of consistent and comparable measures, the report recommends. Currently, the method used by many health care insurers and providers to document how many of their patients have completed the recommended series of vaccinations excludes certain high-risk populations. Without a coordinated, community-wide tracking system, some individuals -- especially children -- will fall through the cracks, undetected by public health officials. For example, a number of managed care plans only report immunizations of children who have been continuously enrolled as patients for one year. This approach tends to undercount or miss children on Medicaid, who must frequently change providers as their eligibility changes or because they are reassigned to new doctors by the system itself.

If distinct pockets of low vaccination coverage, particularly in poor communities, remain undetected, they will provide a reservoir for future disease outbreaks, the report says. National surveys indicate that 9 percent fewer poor children complete the full series of the most critical vaccines than other children. In addition, immunization rates for high-risk adults are especially low, particularly for hepatitis B, tetanus, influenza, and the bacteria that cause pneumonia.
Further, the complexity and magnitude of the task are likely to increase. The federal government continues to expand the list of vaccines recommended for widespread use, as well as the target age groups that should receive vaccines. As a result, immunization costs can be expected to rise, as will the difficulty of managing the system, the report says. Yet some states already have had a hard time integrating new vaccines. For example, in 1998 -- two years after a CDC advisory panel recommended the chicken pox vaccine for children between ages 1 and 12 -- the national pediatric immunization rate for this vaccine was only 43 percent.

The patchwork of private health care providers and federal, state, and local government services that make up the national immunization system also add to the complexity. While patients have greater access, making it more likely that they will get vaccinated, public health officials are finding it increasingly difficult to monitor the effectiveness of the system since the majority of shots are delivered in private health care facilities. The tracking is especially difficult in the case of children who must move on and off of the Medicaid rolls. Yet even as the system becomes harder to manage, federal grants supporting the immunization infrastructure have been cut by more than 50 percent. As a result, long-range data collection, assessment of immunization rates, and strategic planning efforts have all suffered, the report says. A handful of states also have cut back on some of the extra locations where children can get vaccinated, such as clinics that provide food stamps.

The study was sponsored by the Centers for Disease Control and Prevention. The Institute of Medicine is a private, nonprofit institution that provides health policy advice under a congressional charter granted to the National Academy of Sciences. A committee roster follows.

Read the full text of Calling the Shots: Immunization Finance Policies and Practices for free on the Web, as well as more than 1,800 other publications from the National Academies. Printed copies are available for purchase from the National Academy Press Web site or at the mailing address in the letterhead; tel. (202) 334-3313 or 1-800-624-6242. Reporters may obtain a pre-publication copy from the Office of News and Public Information at the letterhead address (contacts listed above).

Division of Health Promotion and Disease Prevention
Division of Health Care Services

Committee on Immunization Finance Policies and Practices

Bernard Guyer, M.D., M.P.H.* (chair)
Professor and Chair
Department of Population and Family Health Sciences
Johns Hopkins School of Hygiene and Public Health

David R. Smith, M.D. (vice chair)
Texas Tech University Health Sciences Center

E. Russell Alexander, M.D.
Professor Emeritus
Department of Epidemiology
University of Washington

Gordon L. Berlin, M.A.
Senior Vice President
Manpower Demonstration Research Corp.
New York City

Steve Black, M.D.
Vaccine Study Center
Kaiser Permanente
Oakland, Calif.

Sheila Burke, M.P.A., R.N., F.A.A.N.
Executive Dean
John F. Kennedy School of Government
Harvard University
Cambridge, Mass.

Barbara A. DeBuono, M.D., M.P.H.
Independent Health Care Consultant, and
Chief Executive Officer
New York Presbyterian Healthcare Network
New York City

Gordon H. DeFriese, Ph.D.*
Professor of Social Medicine, Epidemiology, Health Policy, and Administration, and
Cecil G. Sheps Center for Health Services Research
University of North Carolina
Chapel Hill

R. Gordon Douglas Jr., M.D.*
Merck Vaccines
Merck & Co. Inc. (retired)
Princeton, N.J.

Walter Faggett, M.D.
Pediatric Consultant
Medlink Hospital
Washington, D.C.

Samuel L. Katz, M.D.*
Wilburt C. Davison Professor Emeritus
Department of Pediatrics
Duke University Medical Center
Durham, N.C.

Sara Rosenbaum, J.D.
Harold and Jane Hirsch Professor of Health Law and Policy
Center for Health Services Research and Policy
School of Public Health and Health Services
George Washington University
Washington, D.C.

Cathy A. Schoen, M.A.
Vice President
Research and Evaluation
The Commonwealth Fund
New York City

Jane E. Sisk, Ph.D.
Department of Health Policy
Mount Sinai School of Medicine
New York City

Barbara L. Wolfe, Ph.D.
Institute for Research on Poverty, and
Professor of Economics, Public Affairs, and Preventive Medicine
University of Wisconsin


Rosemary A. Chalk
Study Director

*Member, Institute of Medicine