Childhood immunization: an investment, not an expense - Preventive Medicine: Strategies For Quality Care and Lower Costs - Illustration

Business & Health, March, 1995

When it comes to childhood immunization in the United States, the health care system scores both high and low for performance. While the vaccination rate for 6-year-olds is impressive-95% of children entering school meet state requirements--the system falls flat in serving infants and toddlers, about half of whom are inadequately immunized. Curiously, this breakdown, one of the lowest vaccination rates in the western hemisphere for children under 24 months, extends deep into the ranks of affluent and well-insured families. And the development of newer vaccines--such as the decade-old hepatitis B vaccine and a forthcoming vaccine for chickenpox--raises questions about duration of protection, public policy, delivery systems, and compliance.

Why don't parents make sure their children get their shots on time? Research shows that the answer has more to do with the whirlwind pace of contemporary life than with barriers posed by cost and supply. Further complicating the issue is the fact that most states require vaccination for diphtheria, tetanus, pertussis, polio, measles, mumps, and rubella, while the Centers for Disease Control and Prevention (CDC) in Atlanta and the American Academy of Pediatrics recommend those immunizations as well as protection against Haemophilus infiuenzae type b, and against Hepatitis B for both infants and adolescents. This disparity makes the reporting of child vaccination rates inconsistent and difficult to interpret.

One of the most revealing glimpses of how immunization lags behind schedule can be gleaned from a 1994 study of 1,500 employees of Johnson & Johnson, in New Brunswick, N.J., a relatively affluent, well-insured, and well-informed group. Only 45.2% of the children of J&J employees were current on all CDC-recommended immunizations at age 2 and only 55.3% were current at age 6. (Using the minimum standard required by many states for school admission, however, the immunization rate for 6-year-olds improved to 90.4%.)

Immunizations were a covered benefit for all participants in the J&J study; many employees were fully reimbursed. Parents were asked what factors inhibited them from taking their children to the physician for immunization. The leading response was inability to get time off from work, cited by 15.9% of those surveyed. Others barriers: the wait to see a physician (13.4%), cost (11.8%), physician office hours (5.9%), getting an appointment (5.2%), and transportation (1.6%). Chart 1 shows show these barriers correlated with immunizations.

No epidemics within memory

Many parents of young children not only are short on time, they also lack firsthand experience of serious infectious diseases that are preventable by immunization. In fact, a 1993 Gallup poll found that 47% of parents were not aware that polio is contagious, 36% did not know that measles could be fatal, and 44% did not know that Haemophilus influenzae type b, is the leading cause of fatal childhood meningitis.

The absence of frightening memories of polio, whooping cough, and diphtheria has helped create widespread complacency. Also, some parents reason that with most of society vaccinated and outbreaks of disease uncommon, their unvaccinated children face little risk. But the measles epidemic of 1989-91, which took more than 130 lives, was a lesson that these diseases can be deadly for unvaccinated children.

Vaccines are highly cost-effective. It is estimated that every year immunization efforts prevent more than 3.3 million cases of measles, 2.1 million cases of mumps, and 1.5 million cases of rubella. The treatment for these would have cost $14 billion, according to Partnership for Prevention, a Washington, D.C.-based advocacy group.

A 1994 study at Battelle Memorial institute, in Washington, D.C., reevaluated the cost and benefits of childhood immunization using current values. "We found that society saves as much as $8.80 in direct medical costs alone for every dollar spent," says Evi J. Hatziandreu, senior health analyst and author of the report.

According to a study reported in JAMA, October 12, 1994, 59% of U.S. babies had not been adequately immunized by the age of 7 months, even though 82% of white babies and 75% of black babies had an adequate number of visits to the doctor during the initial 7 months of life.

This suggests that some of the responsibility for low immunization rates lies with physicians. Part of the problem stems from the fact that many doctors are reluctant to immunize children who have minor illnesses, say experts. But they argue that this concern should often be outweighed by the need for timely immunizations to protect against spinal meningitis, pertussis, and other illnesses that threaten a child during the first year of life. Missed opportunities

So prevalent are these "missed opportunities" that the CDC launched studies in 1991-92 in four metropolitan areas to learn more about them. The research, which was reported in 1994, was based on medical records of 2-year-olds.

It found missed opportunities occurred among 75% of the children studied in Baltimore, 69% in Los Angeles, 64% in Philadelphia, and 82% in Rochester, N.Y. The CDC recommends improving vaccination records, assessing the vaccination status of children at every contact with the health care system, not delaying vaccination because of minor illness, and administering vaccines simultaneously.