Facing unprecedented demand for three childhood vaccines, Massachusetts health authorities have begun rationing the state's reserve, fueling fear among some pediatricians that a dangerous gap in coverage might result.
The state quietly issued a memo to doctors late last year telling them to limit their use of certain state-supplied shots for meningitis, diphtheria, and chickenpox, primarily in older children. There is only enough vaccine left to mainly cover seventh-graders, the group that is routinely given the shots.
As a result, older children who are getting caught up on those shots will not have access to free vaccinations. Private insurers, the federal government, and, in some cases, families will have to pay for them.
This is the first time the state has confronted such an imbalance between supply and demand, said Dr. Alfred DeMaria, the state's director of communicable disease control. For example, the state bought 84,611 doses of the chickenpox vaccine for the budget year that began July 1, but in October orders from doctors reached nearly 55,000.
Massachusetts has long been a national leader in buying vaccines for children and then distributing them to doctors, a policy that spawned a seamless delivery system and yielded the highest vaccination rates in the United States. Pediatricians warned that the limits this year could create a patchwork of coverage and lead to lower vaccination levels, not only putting children at risk but also unvaccinated adults who are vulnerable to infection because of chronic health conditions.
"I find it a deplorable decision," said Dr. David A. Link, chief of pediatrics at Cambridge Health Alliance and Mount Auburn Hospital. "What will happen is there will be an outbreak and then someone gets seriously harmed or dies. And we'll all be shouting and screaming at the State House, and then we won't be able to get the vaccine fast enough."
The roster of childhood vaccines has expanded dramatically in the past two decades: In 1985, just seven were routinely administered. Now, there are 16 given from birth through adolescence, providing a shield of protection against diseases from measles to meningitis. Overall, the state paid nearly $850 last year to fully immunize each child, up from just $9.20 in 1983.
The Legislature decided last year not to pay for the new vaccine against human papilloma virus, which causes cervical cancer.
In the past, as shots were added, the Department of Public Health typically bought enough to cover the children in the age group recommended and a little more to help older children catch up. It was a system that worked, with supply sufficient to satisfy demand, until now.
DeMaria attributed part of the heightened desire for the vaccines to aggressive marketing by pharmaceutical companies and part to doctors. "They want kids to get these shots," he said.
Mary Elizabeth Blake, a spokeswoman for
The three vaccines that the state has placed limits on include a new vaccine for meningitis that is given in the seventh grade. Another known by the acronym TDAP is a booster shot given at the same age to strengthen protection against tetanus, diphtheria, and pertussis, also known as whooping cough. The third shot is a second dose of chickenpox vaccine, which federal authorities now recommend for kindergarteners or seventh-graders.
Dr. Sean Palfrey, a former president of the Massachusetts chapter of the American Academy of Pediatrics, said that the state's restrictions on the vaccines have already led to confusion in doctors' offices, with staff now forced to determine who qualifies for free state shots and who will get vaccine from other sources.
"What this is doing to the pediatricians is they are having to not just order stuff through the [Department of Public Health]; they're having to order it through pharmacies and manufacturers," said Palfrey, a professor of pediatrics at the Boston University School of Medicine. "We've been number one in vaccination rates not just because we have vaccine, but because we've set up a system and a communal motivation to do universal distribution."
DeMaria agreed in an interview that the restrictions are disruptive for physicians. "I recognize it's much less convenient to go through all that paperwork, and I wouldn't want to do if it I was in practice," he said.
The state has no plans to buy additional doses of the high-demand vaccines, DeMaria said, in part because over time, fewer children will need catch-up shots. In the current budget year, the state will spend a total of $40 million to buy pediatric vaccines.
Representatives of the three biggest insurance companies in the state said that most of their plans cover all federally approved vaccines. They did not have data available indicating whether there has been an increase in claims for the vaccines since the state began limiting its supply.
Dr. Jerome O. Klein, a pediatrics professor at Boston University, said he does not think the new restrictions indicate that the state is giving up its commitment to childhood vaccinations.
Still, Klein acknowledged that the state has multiple priorities competing for limited dollars.
"There is a price to pay, and it does run up against bridges and housing and other costs," Klein said. "There's no question that the vast majority of children are being immunized, but there are some children who are falling through the cracks."
Stephen Smith can be reached at stsmith@globe.com.
