political will to improve immunization levels exists, many apparent financial and bureaucratic barriers can be overcome.

Governors, legislators, and health officers all need to recognize the importance of immunizing preschool children and the special responsibility that the state has in ensuring that they are immunized. Furthermore, these officials can exercise authority and influence on behalf of new programs that lower-level officials often cannot. David Smith observed that strong support from the Texas governor has made continued progress in immunization efforts possible in that state. Understanding the importance of support at these levels of state government, the Every Child By Two immunization campaign initiated by Rosalynn Carter and Betty Bumpers has targeted governors and other elected officials and their spouses.

State officials also need to know that current approaches to immunizing children are not sufficient to reach the 1996 target of 90 percent coverage. To guide the development of new programs and the allocation of funding and other resources, states must have comprehensive information on children's unmet needs for immunizations and on the factors that keep them from receiving those immunizations. Some of this information will come from the CDC diagnostic projects (mentioned in Chapter 1) and other research studies such as those reported on at the workshop, from CDC surveys, and from tracking and other improved information systems.

Beginning in 1992, states and 24 major urban areas had the opportunity to obtain supplemental grant funds from CDC to assist them in developing and implementing Immunization Action Plans (IAPs) to improve immunization levels among preschool children.2 These funds give states and urban areas the opportunity to move ahead with reducing barriers to immunization, enhancing the infrastructure for vaccine delivery, and supporting immunization information and education activities.

IAPs are intended to support improvements in the delivery of public and private immunization services, but the initial focus has been on the public sector. With the first results of CDC's telephone surveys in November 1994, the IAP areas will have the comprehensive population-based data necessary to assess the need for immunization services and the impact of enhanced service delivery in both the public and private sectors.

The committee encourages states and communities to work with CDC to ensure that IAPs promote comprehensive planning across the public and private sectors. The application process for the Robert Wood Johnson Foundation's All


The $45 million in awards made in April 1993 represented only 20 percent of the additional funding that states estimated that they needed (Walter Orenstein, CDC, personal communication, December 1993). For fiscal year 1994, funding was increased to $129 million.

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