FIGURE 1 Estimated vaccination coverage with the 4:3:1:3 series, by coverage level and state. Source: Calling the Shots. Institute of Medicine (2000).

Among older adults (ages 65 and over) living in the community (i.e., not in nursing homes or other institutional settings), 67 percent reported in 1999 that they had received an influenza vaccination in the previous year, and 54 percent had ever received a pneumococcal vaccination (CDC, 2001). Immunization rates for high-risk adults ages 18 to 64 are particularly low, with data for 2000 showing that only 32 percent of this group had received an influenza vaccination in the previous year (CDC, 2002b). Low influenza immunization rates among “high- risk” children and adults younger than age 65—those with asthma or other chronic health conditions—are of particular concern.

Immunization levels are also persistently lower among low-income children and adults. Although the annual NIS and other state-based immunization surveys provide estimates of general population immunization coverage levels, they frequently rely on telephone household surveys that do not include estimates for pockets of high-risk, underimmunized populations represented by groups such as public housing districts or neighborhoods characterized by deep poverty (U.S. General Accounting Office, 1996). For example, one survey of coverage rates in 1997 for inner-city, African-American children in Los Angeles found that only half (50.6 percent) of the control group (which did not participate in a case management intervention) were up to date at 1 year of age, a marked contrast with the NIS estimates of 83 percent for the nation and 86 percent for Los Angeles County (Wood et al., 1998). Similarly, a 1994 Chicago



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