Published by: Kiran Sreenivas on 7/26/2011 11:57:07 AM
We are in the midst of the ‘Decade of Vaccines’. (Did you not get the memo sent out by the Bill and Melinda Gates Foundation?) While many may see vaccines as an issue restricted to developing countries trying to prevent rotavirus-caused diarrhea, the truth is that the issue of vaccines is and almost always will be an issue within the United States. The dialogue just changes.
Vaccines were heralded as the greatest thing since sliced bread in the mid 20th century with the eradication of smallpox and the reduced prevalence of infectious diseases like measles and diphtheria. Then there was concern over a possible causal association between the measles-mumps-rubella (MMR) vaccine and thimerosal-containing vaccines with autism. A scientific review by the Institute of Medicine (IOM) rejects this notion.
More recently there have been lively debates on possibly mandating the human papillomavirus (HPV) vaccine Gardasil for young girls. Twenty states have enacted legislation that require, fund, or educate the public about the HPV vaccine. Growing evidence shows that boys may also benefit from HPV vaccination. Genital warts, anal cancer, penile cancer, and cancers of the back of the throat and tonsils have been linked to specific HPV strains covered by Gardasil. The FDA has already approved Gardasil for boys and young men ages 9 to 26. Part of the domestic dialogue today is when does vaccine research become action worthy?
Another part of the dialogue is what role should cost play in newer vaccines? The Advisory Committee on Immunization Practices (ACIP) makes recommendations used by both the government and private insurers on what vaccines to cover. In 2009 they decided it was not cost effective to vaccinate boys for HPV, but it was for girls. This decision came after a 2005 decision where the ACIP decided to put aside cost-benefit analyses and recommended every adolescent get a meningitis vaccine at a cost of nearly $100 a dose. Last year the ACIP had to decide whether to recommend a meningitis vaccine booster. They did, which means the government alone shoulders an annual cost of $387 million to prevent 23 deaths from meningitis.
A third part of the dialogue is how do we ensure equal access? Up to 20% of privately insured children may not have their immunizations fully covered. There are millions of children who are Medicaid or CHIP eligible but not enrolled. The Vaccines for Children (VFC) program is a federal entitlement program that helps alleviate these problems by covering immunization costs for Medicaid-eligible, uninsured, American Indian or Alaskan Native, and underinsured children. VFC, however, is limited to Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC). This creates a gap for children served in public health department clinics. Low reimbursements from VFC and other payers make some providers question whether they should continue to provide vaccines (Bednarczyk 2011).
Earlier this month $95 million in grants were disbursed as part of the Affordable Care Act to help school-based health centers provide a range of services from immunizations to bandaging scraped elbows to providing mental health support. Having a usual source of care is important as many vaccines, like Gardasil, require multiple doses in a timely manner. Hopefully these school-based health centers will remain effective and viable.
It may begrudge some, but our domestic vaccine dialogue should include discussions about the international scene. Disease knows no borders, and the not too distant influenza pandemic scares are a reminder of that. Also, the U.S. can have a substantial impact on global efforts by providing financial and technical support. Unfortunately, the U.S. can also hinder efforts when the CIA conducts a fake vaccine program in Pakistan to collect DNA samples. Pakistan is one of the few places where Polio remains endemic, and it is hard to imagine people there trusting future vaccination efforts. A ‘Decade of Vaccines’ will be a challenge both domestically and internationally.
Reference
Bednarczyk, RA and Birkhead, GS. "Reducing financial barriers to vaccinating children and adolescents in the USA." Current Opinion in Pediatrics 23.1 (2011): 105-9.