ANN ARBOR, MI - When a new vaccine to protect infants and children against meningitis, pneumonia and ear infections was introduced last year, the public's response was overwhelming: parents clamored to get their children vaccinated, as advertising and media coverage touted the shot's effectiveness. Within months, supplies of the vaccine had become scarce.
But some doctors who care for children - including those who recommend the pneumococcal conjugate vaccine, known as Prevnar - are expressing concerns that the vaccine is too expensive, adds yet another injection to infants' already vaccine-heavy office visits, and initially wasn't covered by many public and private insurers, creating an unequal situation for some kids.
The doctors were interviewed by University of Michigan Health System researchers as part of a pilot survey of two dozen physicians in seven states conducted for the Centers for Disease Control and Prevention and published in the new issue of Ambulatory Pediatrics. The study points out issues that may have significance for the introduction of future vaccines now in the pipeline, says lead author Matthew Davis, M.D., M.A.P.P.
Davis, a lecturer in pediatrics and internal medicine, and member of the UMHS Child Health Evaluation and Research (CHEAR) Unit, conducted the survey with U-M colleagues to provide early data to the CDC within months of Prevnar's introduction, and to pave the way for a larger national survey of more than 1,000 physicians, the results of which are still being analyzed.
"Doctors have been caught in the middle with this vaccine's introduction, and even those who are recommending it to their patients' parents express strong reservations about the financial and social issues it has raised," says Davis. "As we look toward the future of vaccination, it appears that primary care physicians want more combination vaccines, lower vaccine costs, and less delay in availability of vaccines for disadvantaged children. Without these, we may see lower childhood vaccination rates, even for new and effective immunizations."
Three quarters of the pediatricians and family doctors contacted for the survey said they were recommending Prevnar for their youngest patients, as endorsed by the CDC and the American Academy of Pediatrics in June, 2000. But the rest were not. The biggest factor causing some to refrain from recommending it, and others to have reservations about doing so, was cost.
Pediatricians and family practitioners often take a financial risk in buying a supply of perishable vaccine, not knowing if they will use it all. Prevnar's high cost - nearly $260 for four doses - made it an especially risky proposition for doctors, and even more so for those in solo practice.
Those parents whose insurance companies decided immediately to pay for Prevnar vaccinations could get the shot series for their children without having to pay out of pocket. Others with high enough incomes could pay for it themselves, though some doctors in the survey described their system of having parents verify up front that they could pay.
But those without insurance, or with public insurance like Medicaid, initially faced either a cost that could be daunting for a low-income family, or at least a several-month wait for government agencies and free clinics to start covering or offering Prevnar.
This inequality didn't sit well with some of the physicians in the new survey, who were not eager to take part in a dramatic example of a two-tier medical system, Davis says. And, the reimbursement rates from both private and public insurers for Prevnar in some cases didn't match the cost to the doctors - making the shot a money-losing proposition for some providers.
Even if money were not an issue, some physicians in the survey expressed concern over the extra four "pokes" needed to give Prevnar over the course of a child's first year - often totaling five injections at an infant's two-month checkup and others given during that year.
Davis explains that some physicians were most concerned about the discomfort this would cause their tiny patients, while others cited worries about "new" vaccines. He speculates that this general concern may have been related to the fresh memory of the rotavirus vaccine - which was pulled from use due to worries about rare but dangerous side effects - and growing parental concerns about other real or supposed vaccine side effects.
The solution to some of these worries would be more vaccines that bundle inoculations against several diseases into one shot, like the measles, mumps and rubella (MMR) vaccine available since the 1960s, Davis says. But for now, the one-disease vaccines are more common, and more are coming in the near future.
"Some doctors said they wanted to move slowly, as the immunization schedule gets more congested and complex," says Davis. "Others said they wanted primary care to have a seat at the table when vaccination recommendations are being formulated, and to see better coordination among manufacturers and insurers in the time between approval by the Food and Drug Administration, and the recommendation announcement."
Though the survey took place before the current shortage of Prevnar arose due to high demand and production problems, Davis adds that the results of his study show how the economics of vaccines can play out at the patient's level.
Working with Davis were Margie Andreae, M.D., a clinical assistant professor and associate director for general pediatric clinical services, and Gary Freed, M.D., MPH, director of general pediatrics and the Percy and Mary Murphy Professor of Pediatrics and Child Health Delivery.
Full reference: Ambulatory Pediatrics, Volume 1, Number 6, November 2001, pages 302-305.
Journal
Ambulatory Pediatrics