to the editor: The article on “Poliovirus Vaccine Options,”¹ written by Zimmerman and Spann, provides cogent reasons for the regimen of combined inactivated poliovirus vaccine (IPV) and oral poliovirus vaccine (OPV). What is not addressed in this or any other article of its type is the issue of vaccine cost and reimbursement.

The authors state that “the costs for IPV and OPV schedules are similar in the private sector.”¹ This is not true in the sector in which I practice (Reading, Pa.). The cost of OPV for my practice is $10, compared with a cost of $35 for IPV. Obviously, reimbursement does not match our outlay. Furthermore, most of the pharmaceutical companies that manufacture vaccines provide major price breaks for bulk purchases or require a $500 minimum purchase. As a solo practitioner who sees a small but steady number of newborns, I am being placed in the position of subsidizing vaccine costs from my diminishing practice revenues.

Even the Commonwealth of Pennsylvania, which mandates coverage of vaccine costs by all insurers, is not helpful because these costs are reflective of bulk purchases and not small lots. Finally, managed health care organizations are often sluggish when it comes to deciding how and when to reimburse for new or altered vaccine regimens regardless of whether reimbursement is realized as fee-for-service or included in capitation. In short, because quality pediatric care mandates correct administration of vaccines, and because the small practice may find it financially difficult to purchase these vaccines in the face of uncertain or inadequate reimbursement, we may be forced out of pediatric practice.

in reply: I practice part-time in an inner city health center of modest size in Pittsburgh, which serves the poor and homeless. Thus, I am personally aware of the problems of price.

The question about an equivalent price was initiated by a reviewer for American Family Physician who read an earlier draft of my article where I listed cost as a disadvantage of inactivated poliovirus vaccine (IPV). The reviewer checked his records and found that the costs were quite similar. I then checked my practice records and found that the costs were similar (IPV is more expensive for the government to buy and the book price is higher). After receiving your e-mail, I asked my office staff to once again check prices. On our last order, we paid $146.30 for 10 doses of IPV ($14.63 per dose) and $144.24 for 10 doses of oral poliovirus vaccine (OPV) ($14.42 per dose). IPV can be ordered from the manufacturer, Pasteur Merieux Connaught (PMC), at 800-822-2463. So, for my inner-city Pittsburgh practice, the prices are equivalent. I ask you to call PMC, ask for the price and let me know.

A patient of my father's practice was a polio victim and a family friend. From watching his decline and struggles, I know of the suffering caused by polio. In national meetings, I have also seen those who have or have a relative with vaccine-associated paralytic polio (VAPP). Persons with VAPP suffer. I believe that an ethical issue is whether or not we continue to use an all-OPV schedule, knowing that a few of the vaccine recipients will be paralyzed from OPV. I cannot do this any longer, unless the child is traveling overseas soon or in some other special circumstance. IPV is clearly safer. Even if a small difference in price occurs, can we ethically continue the all-OPV schedule routinely when indigenous, wild polio has been eradicated in the United States for years?