the use of standing orders to vaccinate adults in clinics, hospitals, and nursing homes. Other interventions—such as school or child care vaccination requirements, home visits to promote vaccinations, and vaccination programs in WIC settings—can be recommended when they are well matched to particular needs and capabilities. In other cases, additional work is necessary to determine whether a specific intervention has the potential to increase coverage levels and to be implemented successfully within different communities. Support and leadership are required from local public health agencies to test the effectiveness of and to implement promising interventions within a given community. Nationwide programs are not the best approach; instead states and local communities need to experiment with multiple strategies. Interventions designed to enhance the use of reminder-recall and assessment and feedback efforts in the private sector are likely to be highly effective. There is also a need for extensive and ongoing collaboration among local public health agencies, private health plans, and public and private health care providers to monitor and improve coverage levels.

Finding 4–12. Data on baseline and current immunization coverage levels are essential for determining the reliability or effectiveness of a selected intervention. Disruptions in data collection and assessment efforts impede the evaluation of intervention strategies and inhibit the determination of best practices.

Finding 4–13. It is unlikely that private health care plans will allocate adequate resources for populationwide services or community activities that promote the health of at-risk or hard-to-reach populations under current contractual arrangements.

SUMMING UP

The continued presence of many vaccine-preventable diseases throughout the world requires a persistent effort within each U.S. state to monitor disease reports and be prepared to respond swiftly to disease outbreaks. Similarly, surveillance and assessment of immunization coverage rates are still required so that discrepancies can be identified and resolved by reducing barriers or creating appropriate incentives within the health care system. Interventions such as assessment and feedback for public and private health care providers and client reminder-recall have been shown to improve immunization rates, and their implementation in a broad range of communities deserves full support. In areas where evidence of impact is uncertain, multiple strategies are necessary until certain approaches have achieved a significant enough impact to warrant



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