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 |
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