related to each state’s overall program. Every state immunization program is concerned with vaccine purchase and service delivery, but variations exist in the scope of the population that is served and the settings in which services are delivered. In most states, the core mission and basic purpose of the state program are focused solely on children, ensuring that they receive the immunizations recommended by ACIP (Freed et al., 1999). At the same time, the state survey and eight case studies prepared for the present IOM study demonstrated significant variation in state activities that reflect differences in levels of need, resources, and local practices (see Appendixes D and E).

Section 317 Infrastructure Support. The vast majority of infrastructure support for immunization within the states comes through Section 317 grant awards administered by CDC. Following the 1989–1990 measles outbreaks, federal and state officials expressed alarm about the adequacy of existing immunization delivery systems and identified strategies designed to improve immunization coverage rates among vulnerable populations.

In the midst of turbulent health care reform and the expanded reliance on private managed care plans to deliver public health benefits to individuals eligible for federal assistance, the increased budget for Section 317 (1992–1994) and the creation of the VFC program (1994) enabled states to do more to improve immunization coverage levels. In the high-funding years of the Section 317 program, states used their grant awards primarily to expand local services (33 of 50 states) and outreach and education (33 of 50 states) (see Table 5–1). About one-third of the states developed new partnerships with WIC clinics (13 of 50 states) or initiated state or regional registries with encouragement from CDC (16 of 50 states). A few states used their federal grants to improve statewide assessment efforts (7 states), expand vaccination campaigns in general or specialized areas (5 states), or add state staff to assist with coordination and policy development (8 states). In addition to the national studies supported by CDC, 11 states conducted their own immunization coverage surveys during 1995–1997, using methods that included annual birth certificate studies, retrospective school surveys, cluster surveys, and registries (see Box 5–3).

Beyond operating their own programs, many states used their Section 317 funds to monitor and help improve immunization rates within the private sector. These efforts, such as the use of Clinic Assessment Software Application (CASA) audits5 and general management of the VFC program, represent important features of the new roles of public health agencies in assessing and ensuring the quality of private health care services financed through public funds. Yet such efforts are often the most difficult to document because they do not constitute a defined “program” in many public health agencies. The ability of health agencies to



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