Immunizations

The evidence clearly supports their use. The recommendations are very straightforward, and the patients generally understand the need for them. So why are immunizations such a challenge to deliver? Despite the availability of an unprecedented number of vaccines for both children and adults, many people fail to benefit from them because of barriers to immunization delivery — some real and some perceived.

First, the real barriers. The most important issue for most physicians is vaccine cost and reimbursement. It now costs well over $1,000 to fully immunize a child and $160–$570 to provide an adult all the recommended vaccines, and those numbers are based on government prices. Private practitioners pay even more. Health insurance plans, both private and federal, often fail to reimburse adequately for vaccine acquisition and administration costs. While improvements have been made in Medi-Cal reimbursement for vaccine delivery, many providers still lose money by giving vaccines. Often left out of the equation are costs for procuring, tracking, and storing vaccines. Physicians need to become better businesspeople and negotiate adequate reimbursements.

A second, frustrating barrier is vaccine shortages. In the past few years we have suffered through shortages of vaccines for influenza, pneumococcus (conjugated vaccine), hepatitis A, zoster, and Haemophilus influenzae. The combined MMRV vaccine hasn’t been available for the past year. This phenomenon is a result of the small number of vaccine manufacturers in the United States. A recent report from Minnesota described the resurgence of H. flu type B disease as a result of the vaccine shortage (MMWR 2009; 58(03):58-60). Fortunately, these shortages have caught the attention of the CDC, the Institute of Medicine, and various legislatures, so hopefully some long-term solutions are on the way.

A third and readily solvable barrier is simply adequate documentation of vaccination. Providers generally overestimate how good a job they do immunizing their patients. Despite that, it has been estimated that up to 20 percent of children receive at least one extra vaccine they don’t need. This all comes down to record keeping, especially important in our highly mobile society. The solution is available but not widely used in San Diego County. Practitioners in San Diego County have access to the free, confidential, Web-based, computerized San Diego Immunization Registry (SDIR) that is maintained by the San Diego County HHSA. This resource allows you to find out what vaccines your patients have received elsewhere, easily document the vaccines you give, and has a number of features to improve your immunization delivery. Anyone interested in learning more should contact the County Immunization Branch at (619) 692-6881 or visit www.sdiz.org.

Now to the perceived barriers. It is amazing that some people, mostly adults, don’t think or don’t know they need vaccines. Only 40 percent of 18–49-year-old adults in San Diego County who should receive influenza vaccine did in 2005, and 50 percent of them said they didn’t know they needed one. Despite a longstanding recommendation that healthcare workers receive influenza vaccine annually, 30 percent who don’t get one say they don’t think they are at risk. Practitioners who care for adults need to do a better job educating their patients.

The biggest of all barriers to immunization these days is unfounded concern over vaccine safety. We’ve all had patients express concern about vaccine safety, but our vaccine supply has never been safer. The FDA is scrutinizing vaccine manufacturing (this has led to some of the shortages discussed above) and the CDC has established three programs to assure vaccine safety. To learn more, visit the Vaccine Adverse Event Reporting System at http://vaers.hhs.gov, the Vaccine Safety DataLink at http://www.cdc.gov/vaccinesafety/vsd, and the Clinical Immunization Safety Assessment Network at http://www.cdc.gov/vaccinesafety/cisa. The most important thing physicians can do to address this barrier is to talk to patients about their concerns and help them find credible sources of information. Provided with accurate information about the risks and benefits of vaccines, patients will choose to be immunized every time.

Vaccines are the most cost-effective prevention strategy we have. Collectively we need to overcome these barriers so that we create a healthier community.