Childhood Vaccinations

Journal of Family Practice, Feb, 2001 by Dilip Nair, Richard K. Zimmerman, Ilene T. Burns

Drs Zimmerman and Burns provided an excellent practical overview of routine child vaccination in a recent supplement to JFP.[1] However, they omitted (perhaps necessarily, given the focus of their article) a major subject of consideration in such a discussion--public health infrastructure. The public health infrastructure that supports the US immunization system has been described in a recent Institute of Medicine (IOM) report as "fragile and unstable."[2] Also, significantly lower coverage rates exist among children from low-income families, particularly those children in low-income sections of metropolitan areas. The IOM report points to the recent drastic reduction of federal funds to the states for support of the immunization infrastructure as one of the key causes of the strain in the system. The report urges the federal and state governments to disburse more money for this purpose.

However, another important contributor to the fragile state of the nation's vaccine coverage infrastructure is the recent emergence of new vaccines and the accompanying recommendations for universal or near-universal usage. It is imperative that immunization policy be formulated with the recognition that resources are limited. This requires that immunization policy be disengaged from 2 very powerful related engines: advances in vaccine technology and unrealistic societal aversion to the risk of adverse outcomes.

A case in point is the heptavalent pneumococcal conjugate vaccine. It is clear that this effective and safe vaccine is a boon, especially for children younger than 24 months among whom the 1999 rates of invasive pneumococcal disease are estimated to be approximately 8 times higher than the overall rate of 22.2 per 100,000 population.[3] However, there are grounds to question universal immunization with this vaccine in this age group. Pneumococcal bacteremia in children of this age is heavily concentrated among certain ethnic and medical risk factor groups. Also, it rarely causes significant morbidity or mortality except in the minority of cases where it is associated with meningitis or in patients who are immunocompromised or asplenic.[3] In addition to this nonuniform population distribution of disease risk, one must also consider that cost-benefit analysis of this policy has been equivocal at current vaccine prices.[4] Finally, the logistic and psychological burden for parents and care providers of yet another recommended series of 3 injections should not be dismissed.

Vaccine technology will continue to advance briskly, and the assumption that all suffering and risk of suffering can be eliminated will subtly advance with it. Unless national immunization policy is freed from these forces, the infrastructure on which national immunization coverage depends will eventually collapse under their weight.

Dilip Nair, MD Marshall University Huntington, West Virginia

REFERENCES

[1.] Zimmerman RK, Burns IT. Child vaccination, part 1: routine vaccines. J Fam Pract 2000; 49(suppl):S22-33.

[2.] Committee on Immunization Finance Policies and Practices, Institute of Medicine. Calling the shots: immunization finance policies and practices. Washington, DC: National Academy Press; 2000,

[3.] Centers for Disease Control and Prevention. Active bacterial core surveillance (ABCs) report: Emerging Infections Program Network: Streptococcus pneumoniae, 1999 (preliminary). Available at: www.cdc.gov/ncidod/dbmd/abcs.> [4.] Lieu TA, Ray GY, Black SB, et al. Projected cost-effectiveness of pneumococcal conjugate vaccination of healthy infants and young children. JAMA 2000; 283:1460-68.

THE PRECEDING LETTER WAS REFERRED TO DRS ZIMMERMAN AND BURNS WHO RESPONDED AS FOLLOWS:

We concur with the comments from Dr Nair and the Institute of Medicine about the fragility of the infrastructure, an issue that was not a focus of our article. Dr Nair suggests that immunization policy be developed recognizing that resources are limited. We agree. Almost all universally used vaccines have favorable cost-benefit ratios from the societal perspective. As new vaccines are developed that reduce suffering, how much should society pay? Where does prevention fit with other issues, such as profits for managed care companies and expenditures for military hardware?

Dr Nair questions universal pneumococcal conjugate vaccination of children aged 2 to 23 months, a policy recommended by the American Academy of Family Physicians, the American Academy of Pediatrics, and the Advisory Committee on Immunization Practices of the Centers for Disease Control. Dr Nair's first concern is that high-risk groups based on ethnicity and underlying medical disease account for the majority of disease and implies that universal vaccination is not needed.

In fact, the majority of cases occur in white children without underlying disease. In a recent study,[1] only 10% of cases with invasive pneumococcal disease had an underlying risk factor. In another study[2] that over-represented African Americans by design, 60% of the cases were among whites. Although it is true that rates are higher in Native Americans and in children with medical conditions such as sickle cell disease, other groups with increased risk include African Americans, children in daycare, passive smokers, infants, and recent users of antibiotics.[1-3] How many risk factors are needed before moving to universal recommendations? Recommendations targeting high-risk groups have largely been unsuccessful in the past; are we willing to take this risk for failing to vaccinate against what is the most common cause of meningitis?