immunization requirements for participation in state-licensed day care and are adding requirements for measles and hepatitis B immunizations for adolescents. Colleges are also requiring evidence of up-to-date immunization. For most preschool children, adolescents, and older adults, however, no universal gateway comparable to school entry ensures that immunizations are up to date.

Delayed immunization for preschool children and for adults has been linked to personal and family characteristics and to barriers and deficiencies in the health care delivery system (e.g., Orenstein et al., 1990; NVAC, 1991, 1994; Schulte et al., 1991; Freed et al., 1993; Szilagyi et al., 1993, 1994; IOM, 1994; CDC, 1995c; Frank et al., 1995; Wood et al., 1995). Family factors include lack of knowledge about immunization requirements, low socioeconomic status, low maternal education, and larger family size. In the health care system, providers may miss opportunities to immunize from practices such as not checking immunization status and not immunizing during minor illnesses. Barriers are created by requirements such as appointments for immunization and a comprehensive physical exam prior to immunization.

The recognition that incomplete immunization poses an avoidable health risk has prompted a variety of efforts at national, state, and local levels to raise immunization rates. Activities include establishing collaborations that can promote responsibility and accountability for immunization, improving provider practices and communication with the public, and developing better information resources. Although the focus is generally on increasing immunization rates, communities also need to ensure that they can achieve their current levels of coverage for future cohorts.

The committee included vaccine-preventable diseases among the health issues used to illustrate the development of performance indicators because of the high morbidity, mortality, and costs associated with these conditions and the availability of vaccines as an effective but underused preventive intervention. The incidence of illness and death is much higher among the elderly, but preventable morbidity or mortality among children should be unacceptable in a community. This is also an issue that touches many segments of a community, including children and their families, the elderly, health departments, private and public health care services, schools, and employers.

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