zation coverage assessments commonly focus on 2-year-olds because older children are usually well immunized as a result of child care or school requirements, because most childhood vaccines must be administered within 24 months after birth, and because the immunization status of this population can reveal shifting health care patterns in different geographic areas and health care settings.

The current vaccine schedule (see Figure 1–1 and Table 1–3) recommends that each infant born today receive between 19 and 23 doses of vaccine, most of which should be administered by 18 months of age, to be fully immunized. In 1987, the cost of fully immunizing a child was $116 in the private sector and $34 in the public sector. One decade later, in 1997, the total costs for the vaccines recommended for children had increased to $332 in the private sector and $176 in the public sector (Orenstein et al., 1999).2 These costs can escalate rapidly. The manufacturer’s list price for the new pneumococcal conjugate vaccine (which is effective against meningitis, bacteremia, pneumonia, and otitis media) is $58 per dose, and the Advisory Committee on Immunization Practices (ACIP) has recommended that infants receive 4 doses of the vaccine before age 2 to complete their immunization (Lieu et al., 2000).

Finally, while vaccine purchase costs have increased in both the public and private sectors, it is important to note that the public sector now bears a larger share of the cost of vaccines. The public-sector discount declined from 75 percent of catalog prices in 1987 to 50 percent in 1997 (Orenstein et al., 1999). A smaller number of vaccines recommended for adults differ by age group (see Table 1–3). Annual influenza vaccine is currently recommended for two categories of adults: (1) all persons aged 50 and older, and (2) all persons younger than 50 with certain chronic conditions, such as diabetes, heart disease, and lung disease (CDC, 2000a). One-time pneumococcal vaccines are recommended for adults aged 65 and older and for younger adults with chronic health conditions. ACIP is considering lowering the age range for this vaccine as well, but as of this writing had not made a revised recommendation. ACIP has also made recommendations regarding adult immunization for hepatitis B, hepatitis A, tetanus, diphtheria, measles, mumps, rubella, varicella, polio, and Lyme disease.

National cost data for adult vaccines are generally not available. According to one estimate, the cost for influenza vaccine ranges from $4.16 to $4.87 in the New York City area and for pneumococcal vaccine from $11.54 in upstate New York to $13.02 in Queens (Poland and Miller, 2000).

In addition to the costs of purchasing vaccines, payers must support many other expenses, including the costs of administering the vaccines (which may or may not be billed separately), and record-keeping costs



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