The role of vaccine policy for herd immunization is compared to the role of Medicare and Medicaid in providing health care for the nation's elderly and lower-income.
For a variety of reasons, this approach has not had the impact we would like. Despite the recommendations, many individuals considered most at risk don't receive annual immunization. In addition, the vaccine isn't protective for everyone. In fact, the elderly and the very young generally are less likely than healthy older children and younger adults to mount the kind of robust immune response that is most likely to prevent severe disease.
Population-based studies in Japan and community- and school-based studies in the US have demonstrated that protection of those vulnerable populations can be greatly enhanced by preventing infection among generally healthy school-aged children and working adults. In this, as in so many other aspects of national policy, the well being of one group cannot be addressed without consideration of the well being of the entire population.
What does the change in influenza vaccine recommendations have to do with health care reform?
Medicare and Medicaid were enacted in 1965. Though they have been amended for a variety of purposes, including expansion of populations and services, the target populations have not changed. They are medical insurance plans aimed at the elderly, children living in poverty, and the disabled. Since 1965, however, medical care, including preventive care, has become both more effective and more expensive for all age groups.
Available technology now allows early recognition of breast cancer through routine mammograms. Blood tests detect susceptibility to coronary artery disease and identify those who would benefit from available preventive medication. And type 2 diabetes can be diagnosed earlier, with more options for treatment. In addition, screening of healthy adults is recommended to detect early evidence of colon cancer, and a vaccine that prevents the infection that leads to most cases of cervical cancer is recommended for all adolescents.
Remaining healthy-whether as a child or an adult-has become very, very expensive, but available evidence indicates that these expenses result in healthier children, longer lives, and a more functional elderly population.
Like prior influenza immunization recommendations, Medicare and Medicaid directly target the populations considered most at risk. But enhancements in technology, pharmaceuticals, and record keeping have made it plausible that those populations may, in fact, be best protected by expansion of available medical services to younger and healthier groups.
Dr. McMillan, editor-in-chief of Contemporary Pediatrics, is professor of pediatrics, vice chair for pediatric education, and director of the pediatric residency training program, Johns Hopkins University School of Medicine, Baltimore.