Valuing childhood vaccines
2003; Elsevier BV; Volume: 143; Issue: 3 Linguagem: Inglês
10.1067/s0022-3476(03)00283-x
ISSN1097-6833
AutoresMatthew M. Davis, Alex R. Kemper,
Tópico(s)Bacterial Infections and Vaccines
ResumoAdministration of vaccines to children in the United States has led to profound reductions in the morbidity and mortality of previously common illnesses.1.Centers for Disease Control and Prevention Impact of vaccines universally recommended for children—United States, 1990–1998.MMWR Morb Mortal Wkly Rep. 1999; 48: 243-247PubMed Google Scholar Childhood vaccines are some of the most cost-effective tools available to physicians and the public health community.2.Shepard D.S. Walsh J.A. Kleinau E. Stansfield S. Bhalotra S. Setting priorities for the Children's Vaccine Initiative: a cost-effectiveness approach.Vaccine. 1995; 13: 707-714Crossref PubMed Scopus (37) Google Scholar, 3.Coffield A.B. Maciosek M.V. McGinnis J.M. Harris J.R. Caldwell M.B. Teutsch S.M. et al.Priorities among recommended clinical preventive services.Am J Prev Med. 2001; 21: 1-9Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar Ensuring high rates of vaccination is integral to sustaining the success of childhood immunization initiatives. However, two challenges threaten to undermine childhood immunization programs: widespread supply shortages and rising purchase prices. Our ability to understand and address these problems will affect the future success of childhood immunization programs. Shortages recently occurred for several universally recommended childhood vaccines: diphtheria-tetanus-acellular pertussis (DTaP), measles-mumps-rubella (MMR), varicella, and pneumococcal conjugate vaccine (PCV).4.Centers for Disease Control and Prevention Decreased availability of pneumococcal conjugate vaccine.MMWR Morb Mortal Wkly Rep. 2001; 50: 783-784Google Scholar, 5.Centers for Disease Control and Prevention Supply of diphtheria and tetanus toxoids and acellular pertussis vaccine.MMWR Morb Mortal Wkly Rep. 2002; 50: 1159Google Scholar, 6.Centers for Disease Control and Prevention Shortage of varicella and measles, mumps, rubella vaccines, and interim recommendations from the Advisory Committee on Immunization Practices.MMWR Morb Mortal Wkly Rep. 2002; 51: 190-197PubMed Google Scholar Vaccine shortages led directly to decreased immunization rates7.Centers for Disease Control and Prevention Impact of vaccine shortage on diphtheria and tetanus toxoids and acellular pertussis vaccine coverage rates among children aged 24 months—Puerto Rico, 2002.MMWR Morb Mortal Wkly Rep. 2002; 51: 667-668PubMed Google Scholar and were characterized by inconsistent distribution of available vaccine in public and private sectors.8.Freed G.L. Davis M.M. Clark S.J. Variation in public and private supply of pneumococcal conjugate vaccine during a time of shortage.JAMA. 2003; 289: 575-578Crossref PubMed Scopus (25) Google Scholar These shortages also caused confusion and frustration among parents and physicians, who expect and value vaccines as a core component of preventive care. Simultaneous shortages for multiple vaccines were reported to result from various production problems and unanticipated levels of demand.9.Abramson J.S. Pickering L.K. US immunization policy.JAMA. 2002; 287: 505-509Crossref PubMed Scopus (21) Google Scholar Common to the various explanations for vaccine shortage is the challenge of manufacturing vaccines as “biologic” materials. The technology required to grow components of many childhood vaccines, especially conjugate vaccines such as Hemophilus influenzae type B and PCV, requires several months of production time. A slow production timeline translates into a limited ability to respond rapidly to shortages. More importantly, another theme implicit in explanations of shortage is that administration of public-program childhood vaccine doses in the United States is the result of a delicate partnership between public immunization programs and private vaccine manufacturers.10.National Vaccine Advisory Committee Strategies to sustain success in childhood immunizations.JAMA. 1999; 282: 363-370Crossref PubMed Scopus (83) Google Scholar, 11.Institute of Medicine Calling the shots: immunization finance policies and practices. The National Academy Press, Washington (DC)2000Google Scholar Private corporations bear responsibilities to their shareholders, including recouping capital invested in research and development and turning a profit on their products. Childhood vaccine manufacturers' profit potential is constrained by the sale of more than 50% of their doses to the public sector at federally negotiated discounted prices.11.Institute of Medicine Calling the shots: immunization finance policies and practices. The National Academy Press, Washington (DC)2000Google Scholar On one hand, discounts make public immunization programs more affordable, but on the other hand limited manufacturers' profits have been blamed for the attrition of vaccine manufacturers in the US marketplace over the last two decades.9.Abramson J.S. Pickering L.K. US immunization policy.JAMA. 2002; 287: 505-509Crossref PubMed Scopus (21) Google Scholar With only four manufacturers in the US market, fewer are available to compensate for others' production difficulties and some vaccines are produced by only one manufacturer. Overall, fewer manufacturers exacerbate shortage situations. A recent US General Accounting Office report concludes that some of the factors that led to shortages have been resolved, but shortages may recur.12.United States General Accounting Office Childhood vaccines: challenges in preventing future shortages.Testimony before the Subcommittee on Public Health, Committee on Health, Education, Labor, and Pensions. US Senate, September 17, 2002Google Scholar Unless the government assumes responsibility for manufacturing children's vaccines—which seems unlikely, based on historical US preference for pharmaceutical innovation and production by private industry—the current public delivery-private manufacturing partnership will not significantly change. A fundamental question is: Are we willing to pay more for vaccines to ensure an adequate supply? The cost of purchasing doses of all vaccine series recommended for an individual child nearly quadrupled from 1985 to 2001, in inflation-adjusted terms.13.Davis M.M. Zimmerman J.L. Wheeler J.R.C. Freed G.L. The cost of childhood vaccine purchase in the public sector: past trends, future expectations.Am J Public Health. 2002; 92: 1982-1987Crossref PubMed Scopus (46) Google Scholar Most of this increase was attributable to the addition of new and increasingly more expensive vaccines to the childhood immunization schedule. These historical cost trends, together with expectations of as many as seven additional vaccine recommendations in the next two decades, indicate that the cost of vaccine purchase in the public sector will exceed $1200 per child through age 6 by the year 2020.13.Davis M.M. Zimmerman J.L. Wheeler J.R.C. Freed G.L. The cost of childhood vaccine purchase in the public sector: past trends, future expectations.Am J Public Health. 2002; 92: 1982-1987Crossref PubMed Scopus (46) Google Scholar Is this a worthwhile investment in our children's health? This question must be answered for each vaccine. Published analyses for currently recommended vaccines suggest that they are cost-effective, and even potentially cost-saving, from the societal perspective.2.Shepard D.S. Walsh J.A. Kleinau E. Stansfield S. Bhalotra S. Setting priorities for the Children's Vaccine Initiative: a cost-effectiveness approach.Vaccine. 1995; 13: 707-714Crossref PubMed Scopus (37) Google Scholar, 3.Coffield A.B. Maciosek M.V. McGinnis J.M. Harris J.R. Caldwell M.B. Teutsch S.M. et al.Priorities among recommended clinical preventive services.Am J Prev Med. 2001; 21: 1-9Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar However, “society” does not pay for vaccines. Rather, vaccine purchasers include government immunization programs, private employers and insurers, and parents. Different purchasers' valuations of certain costs and potential future benefits are fundamentally distinct from the societal perspective, and from each other. For example, when the federal Vaccines for Children (VFC) program purchases vaccine for children enrolled in Medicaid, the government directly benefits from decreases in Medicaid health care costs because of prevented illness, while those children remain enrolled. In contrast, a private employer may decide not to cover that same vaccine in its sponsored health plan because most benefits are likely to occur several years in the future, when employees and their dependent children may no longer be covered under that employer's plan. Parents may decide not to pay out of pocket for that vaccine series, because its price exceeds what they perceive as the largely uncertain benefit of preventing future illness. Therefore, despite the fact that childhood vaccines benefit society as a whole, decisions about paying for those vaccines are made by private and public entities with different perspectives. Private employers and insurers who do not offer coverage for recently recommended childhood vaccines, and parents who opt not to pay out of pocket, shift the responsibility for vaccine purchase to the public sector, where government programs purchase recommended vaccines for children who are underinsured for vaccines. As a result, fewer doses are purchased at private-sector prices, and manufacturers face greater pressure to ensure profitability. Ultimately, with continued “shunting” of private demand to the public sector, government immunization programs are asked to shoulder an increasingly disproportionate fiscal burden. One option available to policymakers is to mandate coverage for all Advisory Committee on Immunization Practices-recommended vaccines through private insurance plans, as suggested by the National Vaccine Advisory Committee.13.Davis M.M. Zimmerman J.L. Wheeler J.R.C. Freed G.L. The cost of childhood vaccine purchase in the public sector: past trends, future expectations.Am J Public Health. 2002; 92: 1982-1987Crossref PubMed Scopus (46) Google Scholar Several states have passed health insurance mandates regarding children's vaccines, and bills were introduced in the 2001-2002 session of the US House of Representatives (H.R. 580) and Senate (S. 1297) to mandate coverage by state mandate-exempt insurance plans as well. Although such federal legislative efforts might restore more private-public balance to the purchase of childhood vaccines, passage of federal insurance mandates is unusual. Barring a shift to a nationalized immunization program for all US children, a key to addressing problems of vaccine supply shortage and increasing costs is to value childhood vaccines more accurately from a variety of stakeholders' perspectives. Here there is a clear research agenda and public policy imperative. Public and private purchasers must realize that “cost-effective” is unlikely to mean “cost-saving” for vaccines in the future; in this respect, vaccines now more closely resemble other pharmaceutical industry products that carry a significant health benefit. More investigation—in both academic and nonacademic settings—is required to characterize the health and economic benefits of newer, more expensive childhood vaccines, as well as the timeframe for realizing such benefits. More broadly, legislators, employers, insurers, and parents making decisions about paying for vaccines should be provided with data that permit them to compare benefits of dollars spent on vaccines to dollars spent on other health and health care initiatives. Such decisions are not easy, and they should not be made in the absence of high-quality data. An additional consideration is that the current system of provision of privately purchased vaccines puts children's physicians at financial risk as they purchase doses for administration and then await reimbursement. Appropriate valuation of children's vaccines, therefore, must also address physicians' concerns about risk-bearing for increasingly expensive vaccines.14.Davis M.M. Andreae M. Freed G.L. Physicians' early challenges related to the pneumococcal conjugate vaccine.Ambul Pediatr. 2001; 1: 302-305Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 15.Lieu T.A. Finkelstein J.A. Adams M.M. Miroshnik I.L. Lett S.M. Palfrey S. et al.Pediatricians' views on financial barriers and values for pneumococcal vaccine for children.Ambul Pediatr. 2002; 2: 358-366Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 16.Davis M.M. Ndiaye S.M. Freed G.L. Kim C.S. Clark S.J. The influence of insurance status and vaccine cost on physicians' administration of pneumococcal conjugate vaccine.Pediatrics. 2003; (In press)Google Scholar Although we expect that society will collectively pay more for children's vaccines in the future than in the past, if public and private purchasers act on their own valuations of childhood vaccines, they will do so with an evidence-based understanding of vaccines as an investment in our children's health.document Download .pdf (.02 MB) Help with pdf files Document 1
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