Finding 5–7. Reductions in federal assistance grants to the states have decreased and sometimes eliminated important local infrastructure efforts in areas related to data collection, technical assistance, immunization assessment, and community outreach.


States have important responsibilities for public health services in general and immunization in particular (IOM, 1994b; IOM, 1988). In particular, they:

  • Adopt policies and practices that influence vaccine coverage and the delivery of immunization services within local jurisdictions (including the adoption of universal purchase policies in 15 states).

  • Create and enforce state mandates for the inclusion of immunization benefits in private health insurance plans.

  • Establish immunization requirements for day care and school entry, as well as long-term health care facilities.

  • Set Medicaid and SCHIP eligibility criteria and provider reimbursement levels within federal requirements, negotiate managed care terms and contracts within the limits of federal mandates, and determine the scope of services to be included in the benefits package above the federal minimum.

  • Distribute publicly purchased vaccines and administer immunizations as part of their responsibility for direct health care for indigent populations.

  • Contract with health plans for state and county employees, set health guidelines for their welfare clients (such as immunization requirements), and provide public health services for the general public.

  • Have historically borne the burden of disease surveillance; containment (initially through the use of quarantines); vaccine safety oversight; and health records management in the areas of infectious disease and, more recently, immunization coverage.

Despite this array of activities, state immunization infrastructure efforts are poorly described in the research literature. States do not track routine expenditures for assessment, assurance, or regulatory activities. The common practice is simply to divide costs between vaccine purchase budgets and program operations as general categories.

Infrastructure Investments and Immunization Programs

Immunization infrastructure encompasses the direct labor, administration, supplies, facilities and equipment, training, and overhead costs

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