A Shot in the Arm : That’s what kids need. More than a dozen shots, in fact, before they enter kindergarten. But everything from confusion to lack of insurance to inconvenience helps prevent that from happening.

A new school year means more than buying new shoes and a fresh lunch box. Proving to school officials that a child has been immunized can send parents riffling through medical papers or madly dashing to the doctor’s office with a totally bummed kid for last-minute shots.

According to the latest government advisory, children should receive 18 vaccinations by the time they enter kindergarten--although most schools don’t require proof for some of the newer vaccines.

And, with the anticipated release of the chicken pox vaccine, which is awaiting final approval from the Food and Drug Administration, yet another immunization may be required in a vaccine regimen that, health experts agree, is already ripping at the seams.

Despite the recent focus on vaccines, parents, too, remain confused about their responsibilities, leaving millions of children vulnerable to serious illness.

“There is a lot of concern about the complexity of the immunization schedule,” says Dr. Ann Arvin, a Stanford University professor who helped test the forthcoming chicken pox vaccine. “It doesn’t matter what wonderful vaccines we have if they cannot be given.”

In some U.S. cities, up to half of all 2-year-olds are not vaccinated for potentially deadly illnesses. In one study of 60 large urban areas, an average of 44% of 2-year-olds were immunized. The vaccines protect children from diphtheria, tetanus, pertussis (whooping cough), polio, measles, mumps, rubella, Haemophilus influenzae type b and hepatitis B.

President Clinton has made childhood immunization a priority, but the Administration has encountered massive logistic problems with its plan to distribute free vaccine for poor and uninsured children.

Moreover, while a free vaccine program would boost compliance rates, experts such as Arvin say the obstacles to getting children immunized are more complex. Besides cost, they include inconvenience, fear of side effects, and the size and complexity of the vaccination schedule.

Because of these problems, health officials are exploring several ways to immunize more children, such as giving vaccines at schools and emergency rooms; better insurance coverage, and reminder systems such as phone calls or postcards to parents.

*

While immunizations are often covered by HMOs and are free at public health clinics, the huge cost still has a lot to do with why kids aren’t being vaccinated, experts say.

In public health clinics, the cost to immunize a child to age 2 has risen 723% since 1981, state health officials report. But during the same period, funding to operate public clinics declined about 14%, with many clinics closing. Outreach programs, which located non-immunized children, were also scaled back.

Even families with health insurance face barriers because many private health plans do not cover immunizations. Parents who pay out-of-pocket for their children’s vaccines at private doctors’ offices can expect to spend at least $450 by the time the child is age 2.

In a study at public health clinics in Contra Costa County, where vaccines cost only a few dollars, researchers found that 24% of the families seeking immunizations for their children had private insurance.

“People with private insurance had two reasons for using the clinics: Private insurance did not cover the cost of immunizations, or the families were confused about whether their insurance covered immunizations,” says Dr. Tracy Lieu, the principal author from the University of California, San Francisco.

Some insurers offer only partial coverage. For example, insurance carriers typically have been slow to cover the newer vaccines, such as hepatitis B. And there are questions as to whether insurers will cover the chicken pox vaccine--called Varivax--which will be one of the most expensive vaccines, costing about $35 for the vaccine alone compared to $5 to $15 for most other shots. Add the doctor’s fees to that, and parents should expect to pay $50 or more for Varivax.

“Chicken pox is a pretty benign disease. Insurers have felt that it isn’t high on the list of illnesses you need to prevent,” Lieu says. “But if you take into account the work time parents lose when their child has chicken pox, we found for every $1 spent on the vaccine it would save $5.40 in lost work time.”

Parents may lose work time caring for a sick child, but few apparently feel they can miss work to get their children vaccinated.

Inconvenience was found to be a major reason parents who have a good income, education level and insurance coverage did not get their children fully immunized, according to a study published in February in the Journal of the American Medical Assn.

Researchers gave questionnaires to 1,500 Johnson & Johnson employees who were eligible for one of three health benefit plans. The study found that only about half of the workers’ children were up to date for immunizations.

When asked why, parents listed cost, the inability to get time off work, the wait to see the doctor, limited doctor’s office hours and transportation problems.

Other studies show that parents are confused about which vaccines their kids should receive and when, Lieu says.

In her most recent study of 600 families in the Kaiser Permanente health-care system, Lieu found that a majority of families with 13-month-old babies did not know when the measles-mumps-rubella shot was due (12 to 15 months).

“Those were the families who were more likely to be late for the shot,” Lieu says.

Childhood immunization practices have become increasingly more complex since 1987, when the Haemophilus influenza type b regimen was added. In 1992, the hepatitis B shots were added, and Varivax is waiting in the wings. Several other vaccines are in the final stages of research and could be added to the schedule later this decade.

Because of this flurry of changes, children in the same family sometimes end up on different immunization schedules. Moreover, several pharmaceutical companies make different vaccine preparations for the same disease, such as Hib, that require different regimens.

“Everyone is aware that parents and pediatricians are dealing with a huge number of vaccines to try and give. The numbers are astounding, even to me,” Arvin says.

Moreover, the two leading authorities on immunization--the federal Centers for Disease Control and Prevention and the American Academy of Pediatrics--differ slightly on what regimen each prefers.

Efforts are under way between the two institutions to agree on a simpler, streamlined schedule that could be widely and easily publicized.

“People say parents fear the risks of vaccinations. I’m not sure the answer is so uncomplicated,” Lieu says. “Perhaps we need to provide more information to parents so they know what vaccine is due when. The schedule is not that hard to follow, but someone needs to tell parents what is going on.”

But parents’ fears of side effects from the vaccines are another significant reason for noncompliance--

although a report released in March by the National Academy of Science shows the risks of any severe side effects from any of the immunizations is “extraordinarily low.”

*

If 90% of the nation’s 2-year-olds are to be fully vaccinated by 1996--a goal set by President Clinton--the way children are immunized will have to undergo a transformation, vaccine experts agree.

Besides the obvious need to make immunizations more affordable, more should be done to promote timely vaccinations, says Dr. Robert S. Daum, co-author of the Chicago study. Daum and his colleagues recommend a computerized, national tracking system so that unprotected children could be immunized any time they came in contact with the health-care system.

Another alternative is to press forward with research on combination vaccines--which would consist of one shot that would cover five or more diseases.

But the research takes time and money, Arvin says.

“I think combination vaccines are what we need to aim for,” Arvin says. “I think it’s feasible. But when you do combination vaccines, you have to test them just like any new vaccine. So it becomes a big logistical problem.

For Parents

* Obtain a copy of the most updated vaccine schedule from a doctor, clinic or state or federal health department (A sample appears at right)

* Get an immunization card from a doctor and keep it in a safe place.

* Have a card updated by the doctor each time your child receives a vaccine.

* If you change doctors or move, get copies of you child’s medical records.

When to Get Those Vaccinations

Shaded squares denote childhood immunization schedule for current vaccines.

DTP (diphtheria, tetanus, Pertussis): 2-6, 15 months and 4-6 years Pollo: 2-6 months and 4-6 years MMR (measles, mumps, rubella): 12-15 months and 4-6 years. (The American Academy of Pediatrics recommends the second MMR dose upon entering middle school or juior high) HIB (Haemophilus influenzae (type b)): 2-6,12-15 months Hepatitis B: For Option 1 (at birth, and 1-2, 6-18 months); For Option 2 (at birth, 1-2, 4, and 6-18 months)

*Note: A combination of DTP and HIB is available.

Source: Centers for Disease Control and Prevention