Breaking the "Immunization Cycle"

The Institute of Medicine (IOM) report, Calling the Shots: Immunization Finance Policies and Practices,1 and the articles in this supplement to the American Journal of Preventive Medicine show that the degree of vigilance required is not diminishing. First, progress in the science of vaccines has expanded and will further expand what effective immunization delivery can achieve. Second, our goals are becoming more refined and more demanding. A generation ago, our goals focused on school entry; now we think in terms of reaching children earlier and with a more complex immunization schedule. Third, changes in finance and the rise of managed care have changed the traditional role of public health agencies. That traditional role, embodied in the public health nurse staffing an immunization clinic, speaks to a smaller share of immunization needs. Fourth, the focus on children must not lead to neglecting older populations. One of the messages of the articles in this supplement is that vigilance is easier when financial support for infrastructure is consistent. The key variable for the size of the immunization challenge is the size of the birth cohort. That variable is not highly correlated with the size of the public purse or political interest in immunization. Those variables respond to the business cycle and the cycle of issues at the center of the public agenda. As much as one wants to be optimistic, realism requires recognizing this low correlation. Still, those who want to achieve and sustain high rates of coverage are not powerless. The political-issues cycle sends issues that are perceived as having been “fixed” off to the periphery. The rise and fall of infrastructure funds provided by the federal government through the Section 317 program may show this cycle at work. But the public health community can influence the definition of the problem. The measles outbreaks of 1989– 1991 helped to define immunization as an area requiring more rather than less effort. The IOM committee report on immunization finance to which this supplement is tied may have a similar effect. The contents of this supplement suggest areas where work must be done. We need to make the various measures of immunization come together to paint a single portrait. We need to explain how service delivery fits into “infrastructure” at a time when managed care, done well, seeks to push service delivery out of immunization clinics and into medical homes. In addition, we have to show that fiscal federalism is not the same as “let the feds pay.” At present, we have a continuum of “fiscal federalisms.” Some states make substantial financial contributions to support universal purchase policies while others get by without dipping into their own funds. Let me conclude by noting two areas addressed in this supplement that will be crucial to achieving the promise of immunization: registries and pockets of need. Immunization registries have consumed significant amounts of resources to develop systems and put them in place. To date, the promise of potential performance has outweighed actual returns. This has less to do with the registries themselves than with the relatively slow adoption of information technology in the health care sector. It would be a lot easier for registries to succeed if every clinician charted on a computer. It may be the case that the potential of registries to improve service delivery will not be realized until the day when computer-based patient records are widespread. Meanwhile, immunization program managers may face difficult choices between supporting further development of registries and activities with more immediate returns. Everyone who has been involved in immunization for a decade or more experienced the measles outbreaks at the beginning of the 1990s. That memory reminds us that the coverage rate in pockets of need is as important as the overall national rate. Johnson et al.,2 writing in this supplement, suggest that there has been an “immunization cycle” in which outbreaks are followed by higher resources, then lower resources and then outbreaks again. If we again face outbreaks, they are most likely to be in the same kinds of places as a decade ago, pockets of underimmunized children. Experience and the National Immunization Survey suggest that there are concentrations of these children in large cities. The concentration of underimmunized children is not recognized in how the federal government allocates support for infrastructure through the Section 317 program. Section 317 allocates dollars to all states; under the IOM committee’s recommendations, it From the School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Address correspondence to: W.L. Roper, MD, MPH, School of Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC 27599. E-mail: bill_roper@unc.edu.