Pediatric Annals

from the guest editor

Lawrence D Frenkel, MD

Abstract

THIS ISSUE

Immunization Issues of the 21st Century, Part I

Abstract

THIS ISSUE

Immunization Issues of the 21st Century, Part I

During the past 60 years, most of the historic infectious disease scourges have been all but wiped out. Of the 13 infectious diseases against which we now (or soon will) routinely immunize infants and children, diphtheria and tetanus were essentially eliminated in the United States in the 1940s, and pertussis disease has been significantly reduced but remains a problem. I can distinctly remember my own bouts of pertussis, measles, rubella, mumps, and chicken pox, as well as participating in the great mass trials and immunization campaigns of the SaIk and Sabin polio vaccines.1·2 Some of us may remember, with sadness, friends and colleagues who became sick or died because of haemophillus influenzae, pneumoccal disease, or hepatitis B. This year, influenza joined the ranks of vaccine-preventable infectious agents against which routine immunization of healthy children is recommended. Soon, hepatitis A may do so as well (see Table, page 491).

Despite such progress, there are people in the United States, including some parents of young children and healthcare personnel, who do not support current immunization practices and public health laws. Only about 75% of children are age-appropriately immunized. A variety of events can contribute to a lack of ageappropriate immunization. (Sidebar)

Some children are denied access to immunizations because of cost considerations while billions of dollars are spent on tobacco products, alcohol, and other drugs of abuse. Arbitrary and capricious rate setting by third party payers (often below the cost of providing these vaccines) has been an ongoing problem for the past several years. Unfortunately, this has been true for both governmentally funded payers and private insurance companies. One solution has been to send children to health department clinics for their vaccinations, but this defeats the "medical home" concept and leads directly to missed opportunities. A medical home is a single place and usually a single provider wherein or from whom a patient may receive quality comprehensive care. Some children do not receive immunizations because of ignorance or carelessness on the part of their parents or guardians, and other children miss immunizations due to deficiencies in our healthcare delivery systems.

Each year for the past few years, major shortages have significantly disrupted progress toward attaining the current US goal of 90% ageappropriate immunization levels. Lack of manufacturing capacity, unexpected demand, and enforcement of stringent manufacturing standards by the Food and Drug Administration have led to these shortages. Additionally, the major media regularly abrogate public duty by highlighting sensational but inaccurate stories about adverse effects of vaccines. This frightens many parents and the lay public who may not understand the concepts of risk benefit, causal relationships, and herd immunity.

Table

TABLE.Recommended Childhood Immunization Schedule - United States, July to December 20042

TABLE.

Recommended Childhood Immunization Schedule - United States, July to December 20042

Some solutions are in sight for removing the barriers to achieving desired age-appropriate immunization levels. For example, the Institute of Medicine3 has recommended vaccine financing strategies to resolve some of the cost issues that detract from access to immunization opportunities and to address some of the vaccine shortage issues.

These recommendations include subsidies for developing new vaccines and continued manufacture of old ones. The lack of profit associated with vaccine production often creates disincentives for the pharmaceutical industry to develop new vaccines or even to continue manufacturing old ones.

The best way to combat the anti-vaccine movement, inappropriate media sensationalizing of adverse effects, and ignorance about immunization in general is effective and widespread dissemination of accurate information regarding the benefits of immunization. These benefits can then be contrasted with the huge risk to unimmunized children and adults who suffer vaccine preventable disease. Missed opportunities can be avoided by eliminating cost issues that detract from the medical home and developing computerized immunization registries that decrease the paperwork associated with immunization activities.

The use of multivalent or multiantigen combination vaccines can decrease costs and missed opportunities and makes vaccination more palatable to healthcare providers, parents, and children themselves. Combination vaccines reduce the "pincushion" effect often associated with the multiple injections during a well child visit that are required in order to keep on the recommended vaccination schedule.

The articles in this two-part issue of Pediatric Annals cover major issues impinging on the development and administration of vaccinations and immunizations, such as herd immunity levels required for control of highly infectious diseases, immunization registries to combat missed opportunities, vaccine safety, vaccine shortages, and the role of combination vaccines. The articles also review several current and emerging vaccines, including measles, varicella, pertussis, rotavirus, Live influenzae, meningococcal, and hepatitis B vaccines.

REFERENCES

1. Francis T. Evaluation of the 1954 poliomyelitis vaccine field trials: further studies of the results determining the effectiveness of poliomyelitis vaccine (SaIk) in preventing paralytic poliomyelitis. JAMA. 1955;158(14): 1266-1270.

2. Sabin A. Status of field trials with an orally administered, live attenuated poliovirus vaccine. JAMA. 1 959; 1 7 1 :863-868.

3. Centers for Disease Control and Prevention. Recommended Childhood and Adolescent Immunization Schedule - United States, January-June 2004. http://www.cdc.gov/mmwr/preview/mm wrhtml/mrn5301 -lmmunizational.htm. Accessed June 21, 2004.

4. Institute of Medicine of the National Academies. Financing Vaccines in the 21st Century. Available at: http://www.iom.edu/Object. File/Master/14/454/O.pdf. Accessed June 18, 2004.

TABLE.

Recommended Childhood Immunization Schedule - United States, July to December 20042

10.3928/0090-4481-20040801-04

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