mental changes in the larger health care delivery system resulting from the growth of managed care. In the wake of these changes, the roles of state and local public health departments became more ambiguous and more complex. The need for direct services diminished as private providers and health plans gradually acquired the capacity and resources to deliver primary care services—including immunizations—to disadvantaged groups. But a new public health role emerged, one that places greater emphasis on the need for data management and the development of community-level health indicators (IOM, 1996, 1997). This role requires multi-sector collaboration so that public agencies can assess coverage rates within small-area samples and respond to specific health care needs when the private sector is not able—or willing—to absorb the costs involved in sustaining high immunization coverage rates among hard-to-reach populations.


In 1998, Congress asked IOM to conduct a study of the Section 317 program and of broader questions regarding appropriate levels of effort to achieve national immunization goals. The study addressed six questions formulated by Congress and the Centers for Disease Control and Prevention. The study committee met during 1999-2000 to collect relevant information and to develop a framework to guide its deliberations.

Fact-finding for the study included several separate efforts. First, a research team directed by Gary Freed at the University of Michigan conducted a series of structured telephone interviews with immunization program officials in all 50 states regarding the effects of changes in federal policies and funding in the 1990s on the goals, priorities, and activities of state immunization programs (Freed et al., 2000). Second, IOM staff and consultants developed eight case studies of state immunization efforts, focusing on the states of Alabama, Maine, Michigan, New Jersey, North Carolina, Texas, Washington, and the counties of San Diego and Los Angeles in California (Fairbrother et al., 2000a).1 Third, members of the IOM committee, staff, and consultants also conducted four site visits in Detroit, Newark, Houston, and Los Angeles to supplement the case study materials with discussions with local providers and immunization program representatives. Fourth, the committee organized an IOM workshop on issues related to “pockets of need” in Washington, D.C., in Sep-tember 1999. Fifth, the committee commissioned background papers on


Each case study is available electronically via the website of the National Academy Press:

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