tives, however, and carried forward large amounts of unspent federal grant monies for several years. As a consequence, federal infrastructure grants declined during 1996–1998. In turn, states had to reduce efforts in such areas as clinic hours and mobile sites; immunization outreach; performance assessment; information and program management; and linkage with community-based programs, such as the Women, Infants, and Children (WIC) clinics. The annual average total of state infrastructure grant awards administered by CDC from 1994 to 1999 was $271 million, compared with an estimated total of $123 million in the year 2000 (see Table ES-1). In the past 5 years (1995–2000), Section 317 infrastructure grants to the states have decreased by more than 50 percent.
The states reported to CDC estimates of state-level annual expenditures for 2000 for vaccine purchase ($109 million) and operations ($231 million). These estimates include support from other federal programs (e.g., Maternal and Child Health grants), state revenues, and private contributions (see Table ES-1).
Conclusion 1: The repetitive ebb and flow cycles in the distribution of public resources for immunization programs have created instability and uncertainty that impeded project planning at the state and local levels in the late 1990s, and delayed the public benefit of advances in the development of new vaccines for both children and adults. This instability now erodes the continued success of immunization activities.
The instability of funding for state immunization programs discourages the development of strategic responses designed to foster disease prevention, improve immunization coverage levels for specific populations and age groups, reduce coverage disparities between low-income groups and the general population, and ensure vaccine safety.
Conclusion 2: Immunization policy needs to be national in scope. At the same time, the implementation of immunization policy must be flexible enough to respond to special circumstances that occur at the state and local levels.
A comprehensive strategy that clarifies the roles and responsibilities of federal and state agencies as well as private-sector providers and health plans is needed to sustain an important intergovernmental partnership in the midst of change and complexity. Consistent policies and practices at both the state and federal levels are essential to foster productive relationships and reduce overlap among multiple programs and services.