be designed to provide both kinds of information, are growing with programs such as All Kids Count, independent registry efforts in several states and communities, and registry and tracking products from private vendors. The committee agrees with those who are encouraging the development of a national system of state-based immunization registries. CDC's new random-digit dialing telephone surveys will provide states with another source of information on children's immunization needs.1 (Information issues are addressed in greater detail later in this report.)


Although responsibility and accountability for immunization must exist at many levels, states have special obligations as holders of the authority to act to protect the public's health. Because the independent efforts of individual providers and communities cannot ensure comprehensive coverage, states must recognize that they have a responsibility to identify and correct gaps in immunization services.

The committee believes that states must formulate immunization plans that systematically address the needs of all children and providers throughout the state in the short term and in the longer term. A broad range of interested parties should participate in the development and implementation of such plans: state and local public health departments, private providers, vaccine companies, payers, community groups, and families. State planning groups also must determine where responsibility for the desired outcomes should lie. Each state needs a unique plan that reflects its particular requirements and resources.

States must assess children's immunization needs and ensure that public or private providers and clinics can provide the services to meet those needs. Finding children who have little contact with the health care system or other social services will pose a special challenge. Optimally, every child would have a medical home with a specific primary care provider, and providers would have responsibility for an identifiable set of children. David Salisbury, director of the immunization program in the United Kingdom, explained that these complementary steps are essential to the success of that program. Establishing formal and meaningful child-provider links for all children is more problematic in the United States, but it may succeed in the environment anticipated under some health care reform proposals.


The results of these surveys will, however, tend to overestimate coverage, because children in families that do not have telephones are more likely to be underimmunized than other children. Planned validation studies using immunization data from the National Health Interview Survey should help CDC compensate for these limitations.

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