• situations in which unprotected children, adolescents, and adults can be unexpectedly exposed to vaccine preventable diseases.

  • Immunization coverage rates require persistent monitoring because declines in immunization status serve as early warnings of greater susceptibility to infectious disease. The federal effort in supporting immunization services has expanded in the past as a result of vaccine preventable disease epidemics or outbreaks (e.g., the emergence of the Salk vaccine for polio in the mid-1950s and the measles outbreak in 1989–1990). What remains uncertain is the scope of an adequate federal investment in immunization services in the absence of a disease outbreak or epidemic. Maintaining an adequate data collection and monitoring system and developing strategies to improve immunization rates in areas of need are key components of our national immunization policy, but the scale of the federal role in these efforts, and the extent to which outreach responsibilities and surveillance of disease rates and vaccine records should be shared between the states and the federal government, remains uncertain.

  • Immunization is an important component of comprehensive primary care. A freestanding immunization system may be necessary at times to improve immunization levels in underserved communities or during disease outbreaks. But ideally, a primary care medical home provides the best opportunity for consistent, up-to-date immunization coverage. However, primary care services are not designed to address population-wide concerns in areas such as disease surveillance, public and professional education, performance monitoring, and vaccine safety.

Our nation's immunization program originated in 1955, when Congress appropriated funds to help states and local communities buy and administer the recently licensed inactivated polio vaccine. The adoption of the Vaccination Assistance Act in 1962, along with other policy changes, institutionalized a federal role in the area of childhood immunization and expanded this role to include vaccines against diphtheria, pertussis, tetanus, and measles as well as polio.5 In the late 1970s, the Carter Administration launched the Childhood Immunization Initiative consisting of new legislation, large public education programs, and support for the creation and enforcement of school entry immunization requirements. Federal efforts declined in the 1980s, including the discontinuation of the National Immunization Survey in 1985.

An outbreak of measles in several parts of the country in 1989–1990 drew public attention and support for strengthening federal efforts in immunization services. First the Bush Administration and later the Clinton Administration worked with Congress to implement a national effort designed to increase immunization rates and to improve the operation of the nation's immunization system. This effort involves an intricate public/private partnership focused on two objectives (NVAC, 1991):

  1. The development of an effective vaccine purchase and delivery system that can supplement private sector efforts and assure access to vaccines for disadvantaged families, and



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