Contents

Title Page and Notice		i
National Academies Statement		iv
Committee		v
Independent Report Reviewers		vii
Preface		ix
EXECUTIVE SUMMARY		1
1	INTRODUCTION	18
	Background	18
	Charge to the Committee	32
	Study Context: The National Immunization Partnership	34
	Six Roles of the National Immunization System	43
	Study Approach	50
	Organization of the Report	52
2	CHANGE AND COMPLEXITY IN THE NATIONAL IMMUNIZATION SYSTEM	54
	Key Changes	55
	Increasing Complexity	61
	Successes and Persistent Problems	66
3	FINANCING VACCINE PURCHASE AND DELIVERY	71
	Private Insurance Coverage of Immunization	74
	Medicaid, Vaccines for Children, and State Children's Health Insurance Program	77
	Medicare	86
	Section 317 Vaccine Purchase Grants	89
	State Vaccine Purchase	92
	Issues in Vaccine Purchase	97
	Summing Up	99
4	BUILDING, MONITORING, AND SUSTAINING IMMUNIZATION CAPACITY	103
	Infectious Disease Prevention and Control	105
	Surveillance of Vaccine Coverage and Safety	108
	Efforts to Improve and Sustain High Vaccine Coverage Rates	128
	Summing Up	139
5	IMMUNIZATION FINANCE POLICIES AND PRACTICES	142
	Private-Sector Roles and Responsibilities	144
	Local Health Department Roles and Responsibilities	152
	State Roles and Responsibilities	156
	Federal Roles and Responsibilities	175
	Summing Up	188
6	SUMMARY FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS	193
	Six Questions and Six Answers	194
	Conclusions	220
	Summary Recommendations	223
REFERENCES		228
APPENDIXES		243
A	Public Health Services Act, Section 317	245
B	Immunization Time-Line	250
C	List of Contributors	253
D	Overview of State Survey	261
E	Overview of Case Studies and Site Visits	263
F	Annual Section 317 Awards to States, 1995–1999	271
G	State Immunization Requirements for School Children	282
H	Committee and Staff Biographies	287
INDEX		295

Boxes, Tables, and Figures

BOXES

1-1	Funding of State Activities Under Section 317 Grant Program	27
1-2	Section 317 Grant Guidance	28
1-3	The Measles Epidemic, 1989–1991	35
1-4	Immunization Infrastructure: The Michigan Example	42
3-1	Examples of Residual Needs That Require State Vaccine Purchase	73
3-2	New Jersey: Carving the Vaccine Administration Fee Out of Capitation Rates	85
3-3	Calculating the Size of the Adult Population That Relies on State-Purchased Vaccines	89
3-4	Calculating the Size of the Child Population That Relies on State-Purchased Vaccines	94
4-1	Alaskan Measles Outbreak in 1998	106
5-1	Small-Area Analysis for Detroit and Newark	148
5-2	Rochester Private–Public Partnership Approach	151
5-3	Sample of State and Local Immunization Coverage Surveys	160
5-4	Total Section 317 Funds Awarded to Support Registries as of July 1, 1999	184
6-1	Conclusions and Recommendations	195

TABLES

ES-1	Recommended Finance Levels for the National Immunization System	12
1-1	Comparison of 20th-Century Baseline and Current Morbidity, Vaccine-Preventable Diseases	19
1-2	Vaccination Coverage Levels Among Children Aged 19–35 Months, by Selected Vaccines (1995–1999)	20
1-3	Universally Recommended Vaccinations	25
1-4	Total Federal Immunization Funding, FY 1999	26
1-5	Estimated Vaccination Coverage of 4:3:1:3 Among Children 19–35 Months of Age by Selected Geographic Areas--United States, National Immunization Survey, 1995–1999	30
2-1	Vaccines in Widespread Use, 1985–2020	58
3-1	U.S. Population Health Insurance Coverage, 1998	75
3-2	Coverage of Pediatric Immunizations by Health Benefit Plans Offered by Employers	76
3-3	Medicaid and Vaccines for Children (VFC) Program, FY 1994–1999	80
3-4	State Children's Health Insurance Programs, 2000	81
3-5	Federal Immunization Coverage Policies for Children Under Medicaid, Vaccines for Children (VFC), and State Children's Health Insurance Programs (SCHIP)	84
3-6	Influenza and Pneumococcal Immunization Rates	88
3-7	Vaccine Supply Policy, January 2000	96
4-1	Vaccine Injury Compensation Program Petitions Filed, Adjudications, and Awards	127
5-1	Main Uses of Section 317 Infrastructure Grant Funds in High-Funding Years (1994–1996)	158
5-2	Annual Awards and Expenditures of Section 317 Direct Assistance (DA) Vaccine Purchase Funds	164
5-3	Estimated Vaccination Coverage with 4:3:1:3 Series Among Children 19–35 Months of Age by Provider Type, Census Division, and State--United States, National Immunization Survey (NIS), 1998	167
5-4	State Responses to Section 317 Funding Cuts	170
5-5	Annual Awards and Expenditures of Section 317 Financial Assistance (FA) Immunization Program Funds	178
5-6	Composition of CDC Immunization Appropriations, 1995–1999, Amounts and Shares	186

FIGURES

ES-1	Six roles of the national immunization system	7
1-1	Recommended childhood immunization schedule--United States, January–December 2000	22
1-2	Amount of new funding awarded as Section 317 Direct Assistance (DA) and Financial Assistance (FA), 1990–1999	39
1-3	Amount of total annual awards of Section 317 Funds, Direct Assistance (DA) and Financial Assistance (FA), 1990–1999	40
1-4	Federal agencies that support immunization services and programs	44
1-5	Immunization core functions	45
1-6	Six roles of the national immunization system	46
1-7	Six roles of the national immunization system, broken down by role	48
2-1	Changes in the childhood vaccination schedule, 1975–2000	56
2-2	Immunization coverage levels with the 4:3:1:3 series, by state	68
3-1	Children receiving VFC vaccines by eligibility category, calendar year 2000	80
3-2	U.S. children's insurance coverage for immunizations	82
3-3	Section 317 Direct Assistance and Financial Assistance expenditures by grantees, 1990–1998	92
3-4	Total Section 317 Direct Assistance awards, expenditures, and balances, 1990–1999	93
4-1	Enrollment of children aged 0 through 5 in immunization registries, by state	118
4-2	Provider enrollment and participation in immunization registries, by state	120
5-1	Federal and state funding for immunization programs per child in 2000, by grantee	162
5-2	Section 317 grant operations funding history, 1995–2001	169
5-3	Immunization activities by funding source	181
6-1	Level of grantee contribution by number of states, calendar year 2000	197
6-2	Level of grantee contributions by program component	198