(IOM, 1996, 1997), including assessing immunization coverage rates, and on responding to immunization and other specific health care needs of hard-to-reach populations.

Although the states welcomed new federal immunization funding in the mid-1990s, many of them found it difficult to expend the sudden and significant increases in Section 317 immunization infrastructure awards during the one-year grant period. As a result, states “carried over” large amounts of these grant funds to subsequent years. By 1996, the U.S. Congress had cut back funding for Section 317 infrastructure grants, indicating its uncertainty that the states needed, or could manage, federal assistance in this area. In 1998, Congress asked that the Institute of Medicine (IOM) conduct a study of the Section 317 program and of broader questions regarding appropriate levels of effort to achieve national immunization goals.

The IOM study committee met in 1999 and 2000 to collect relevant information and to develop a framework to guide its deliberations. In support of the study, a research team at the University of Michigan was commissioned to conduct a series of structured telephone interviews with immunization program officials in all 50 states regarding the effects of changes in federal policies and funding during the 1990s on the goals, priorities, and activities of state immunization programs (Freed et al., 2000). IOM staff and consultants developed eight case studies of public-sector immunization efforts in Alabama, Maine, Michigan, New Jersey, North Carolina, Texas, Washington, and Los Angeles and San Diego counties in California (Fairbrother et al., 2000b).¹ Site visits to Detroit, Houston, Los Angeles, and Newark allowed for discussions with local providers and immunization program representatives that supplemented the case study materials. A workshop examined issues related to “pockets of need.” The committee also commissioned background papers on topics such as adult immunization, registries, measuring immunization coverage (Fairbrother et al., 2000a), and federal immunization policy (Johnson et al., 2000). Selected materials from the case study reports and commissioned papers were published in October 2000 in a supplement to the American Journal of Preventive Medicine.