Why the United States has failed to protect thousands of children from deadly diseases.
By Mel Friedman and Ellen Weiss
Today modern medicine can protect children against a host of illnesses, including polio, measles, mumps, rubella (German measles), diphtheria, pertussis (whooping cough), tetanus, and hepatitis B. Yet since 1980, more than 222,000 cases of preventable diseases‑most affecting children‑have been reported to the Centers for Disease Control and Prevention (CDC), in Atlanta. Consider these facts:
Between 1989 and 1991, measles struck more than 55,000 people, primarily preschoolers.
In 1992 there were 16 percent more cases of whooping cough than in 1987.
Between 1965 and 1991, the polio‑vaccination rate among preschoolers was unchanged: Up to half still do not get their full series of polio shots.
Most shocking of all: Recent World Health Organization figures rank the United States third from the bottom in the percentage of 1‑year‑olds who have been immunized in the Western Hemisphere‑behind countries such as Cuba and Honduras.
Timely access is critical.
Why are so many of our children falling victim to these diseases? The problem, experts note, is not with existing vaccines, which are safe (see "The Shots Kids Need," page 43) and more than 95 percent effective, but with timely access to them. Currently children must complete 80 percent of their vaccinations‑that's 14 or more doses‑during their first two years of life. Yet according to the CDC, less than half of all 2‑year‑olds have received their recommended shots.
"Vaccine delayed is the same as vaccine denied," states Louis Z. Cooper, M.D., director of pediatrics at St. Luke's‑Roosevelt Hospital Center, in New York City. This means that America's children are defenseless when they come in contact with infectious diseases, setting the stage for fast-spreading epidemics.
When vaccination levels in a community surpass 80 percent to 90 percent, "the chances that a sick person will infect a susceptible person go down," says Walter Orenstein, M.D., director of the CDC's National Immunization Program. The community then becomes disease‑resistant‑a phenomenon known as "herd immunity." Current vaccination levels among children under 2 years of age are too low to confer herd immunity. And while immunization rates are lower among black people, poor children, and children who live in urban areas, such rates are not restricted to these groups.
The clearest sign that children are at risk came in 1989 with the outbreak of a three‑year measles epidemic. Because measles is highly contagious, outbreaks indicate that millions of children are unprotected, not just against measles but also against other diseases. Federal‑government figures reveal that from 1989 to 1991, the epidemic hospitalized more than 1,000 people, caused more than 130 deaths, and cost the health‑care system more than $150 million.
The epidemic is all the more tragic because ten years ago, widespread use of a potent measles vaccine slashed the number of reported cases from more than 400,000 annually to less than 1,500. According to the National Vaccine Advisory Committee, the epidemic had one major cause: "failure to deliver vaccine to preschool children on schedule," says Kay Johnson, a committee member and director of policy for the March of Dimes Birth Defects Foundation, in Washington, D.C.
Are rising costs at fault?
Four elements are necessary to ensure immunization of all those who need it: There must be an adequate supply of affordable vaccines; parents must be aware of the urgency of immunizing their babies during their first two years of life; all children must have access to vaccinations, regardless of their ability to pay; and health‑care providers must have a reliable system for reporting, tracking, and notifying parents of a child's immunization status so that no child misses a shot or receives the same one twice.
To date, America's delivery system has fallen short in each of these areas, primarily because of the spiraling costs of immunizations. The price of a full series of vaccinations is more than 10 times higher than it was ten years ago. In 1982 the cost was $23. Today a family using a private pediatrician pays about $240 (excluding doctor's fees, which can double the cost) to give a child every shot that he needs by the age of 2.
Vaccine manufacturers maintain that rising costs were necessary during the 1980's to sustain research and development, to insulate firms from potential liability suits, and, after 1982, to pay for a tax that finances a fund for children injured by vaccines. Also, more vaccines and doses of vaccines are required today than a decade ago. "We're in the business of saving lives, and we do it for less money than the mother of a newborn spends on diapers in two months," says David J. Williams, president of Connaught Laboratories, a vaccine developer and manufacturer in Swiftwater, Pennsylvania.
Yet even that may be out of the price range of most Americans. Based on 1991 data, more than one U.S. child in five lives in poverty, according to Martha Teitelbaum, Ph.D., senior health analyst of the Children's Defense Fund, in Washington, D.C. And less than half of all employer‑based health‑insurance plans cover vaccinations. A recent survey by the American Academy of Pediatrics (AAP) reveals that nearly 50 percent of private pediatricians refer some or all insured children to public-health clinics, which typically provide vaccinations free of charge, because their families cannot be reimbursed for shots. A 1991 study, for example, found that between 1979 and 1988, there was a 700 percent increase in the flow of children into the area's public‑health system. Most parents cite cost as the major factor in their decision to turn to public clinics.
Public clinics provide free vaccines, but children still fall through the cracks.
A new immunization law offers hope.
This scenario could change, thanks to a law addressing pediatric immunization that President Clinton signed this past August and is scheduled to take effect in October of 1994. Under the law, the federal government will buy and distribute vaccines to participating doctors, who will then give children free vaccinations or charge a nominal fee for administering them. Physicians cannot, however, turn away youngsters whose parents are unable to pay.
This should help take some pressure off public-health clinics‑which will continue to give free immunizations‑while making lifesaving vaccinations accessible to millions of American children. "While this won't solve the vaccination crisis, it is a step in the right direction," says Joe Sanders, M.D., executive director of the AAP.
Once health‑care reform occurs, the federal‑purchase program will probably be phased out because immunization is likely to be among the universally assured benefits.
Even with affordable and accessible vaccines, however, educating parents will be critical, according to Sanders. In the late 1970's, the Carter Administration persuaded states to pass laws requiting proof of vaccination upon school entry. As a result, immunization levels among 5‑year‑olds jumped from 65 percent in 1977 to 95 percent in 1981. The goal was to reach all 2-year-olds by 1990. But during the 1980's, spending on social programs‑including preventive health care for children‑was reduced.
As a result, "parents came to believe that their children only needed to get their shots by school age,' points out Betty Bumpers, cofounder of Every Child by Two, a Washington, D.C.‑based immunization‑advocacy group. That critical shift in thinking left‑and continues to leave‑many preschoolers vulnerable. "Many parents no longer understood that childhood diseases remained life‑threatening," adds Jennifer Perry, executive director of the Children's Action Network, in Los Angeles, which sponsors the National Immunization Campaign. President Clinton's initiative is expected to address these problems through more funding for immunization-education programs.
Reducing missed opportunities is critical.
Even when armed with the knowledge that vaccinations are essential, many parents encounter obstacles. Nine out of ten babies receive at least one dose of some vaccine before their first birthday. But "the rate quickly falls off by age 2," says Kay Johnson.
One reason is that there is no federal law requiring that toddlers be immunized. Moreover, increased demands on clinics have led to breakdowns in vaccine delivery. "During the measles epidemic, about one third of the children who got measles had a previous health visit in which an opportunity to vaccinate had been missed," says Johnson.
Many clinics require their patients to have an appointment or doctor's referral before shots are I given. Others are understaffed, difficult to reach by public trans transportation or open only during working hours. At press time, Congress was expected to approve funding that would enable clinics to hire more staff, extend their hours of operation, and identify those children who need to be immunized.
But none of these efforts can succeed without a national remind‑and‑recall system, which is likely to be included in upcoming legislation. A central database would tell vaccine providers which shots a newly arrived preschooler‑or a child who may have switched clinics‑may be missing. Routine reminders would also tell parents when their child is due for a vaccination.
In the end, everyone will benefit. From an economic standpoint, immunization may be the most effective prevention available in health care. "It's one of the few areas in which we can prove that a dollar spent now saves ten later on," says Cooper.
"Our children represent the future," adds Lori Hansen Riegle, head of the congressional branch of Every Child by Two, and wife of Senator Donald W. Riegle (Democrat of Michigan), who sponsored the immunization bill. "It's critical that they be healthy."
Above all, it's a health necessity. "Even though it has been 40 years since we've seen iron lungs, we must recognize that polio can come back," says KennethJ. Bart, MD., associate director for child health in the Office of International Health. "We've become too complacent, and in the absence of maintaining our guard, diseases will return."
Mel Friedman and Ellen Weiss are free‑lance writers living in New York City. They are also the parents of a l4‑year‑old.
“My child almost died”
Regina Alston's unvaccinated daughters had to fight for their lives.
From December 1992 to May 1993, Regina Aiston's three daughters battled a siege of pertussis, better known as whooping cough, that ran up thousands of dollars in medical bills and nearly claimed the life of Regina's newborn. When her eldest daughter, Kristin, had a bad reaction to the pertussis portion of her first DTP (diphtheria‑tetanus‑pertussis) shot, Regina decided not to let her have any more of the pertussis vaccine. Regina then let Brandi, her second daughter, go unvaccinated against pertussis too.
Last winter Kristin caught whooping cough and infected her sisters, including Shelby, who, at 1 month, was too young for a DTP shot. Kristin's illness was the least severe because she'd had one dose of vaccine. But it hit Brandi hard, and Shelby, who stopped breathing, battled for her life.
With emergency care the critical period passed, and all three girls were put on medication for four months. The children eventually recovered, but aftereffects linger: Shelby catches colds easily, and Brandi is susceptible to bronchitis, and coughs at night. "People have been misinformed about the DTP shots," says Regina. "I don't care how many second thoughts you have‑give your child these shots, because the diseases are far worse."