to supplement and support state efforts through policy coordination, technical assistance, and data collection. Federal grant awards also offer assistance to help states improve their ability to meet the needs of underserved populations, including the uninsured and urban poor, rural residents, immigrants and migrant workers, the elderly, and infants and children. As discussed earlier, federal immunization grants to the states expanded to include infrastructure support in the early 1990s, allowing the states to use federal funds to hire personnel and contractors for specific purposes such as outreach, data collection, and program development.

• Federal initiatives—In addition to state assistance, the federal government has undertaken special initiatives to expedite the introduction of new vaccines or technologies into the health care system; to reduce inequities in access to immunization services; and, more recently, to address concerns about the safety and quality of vaccines. These initiatives require close collaboration with the states to ensure that federal funds are distributed according to the priorities of the federal program, rather than simply augmenting state revenues for public health.

The combination of state assistance and federal initiatives has evolved through a series of special programs and policies (see Appendix B). The result is a patchwork quilt of policy guidance that places particular emphasis on certain issues while omitting others. By using their Section 317 grant awards, states were able to stitch this quilt together in a cohesive manner that responded to local needs and circumstances. As funds were reduced, states were forced to balance responding to local conditions while also complying with federal mandates.

Federal investments in immunization programs in the 1990s had two basic objectives: (1) improving immunization coverage rates and sustaining high rates among hard-to-reach populations using a variety of evidence-based prevention and linkage strategies, and (2) integrating immunization services within comprehensive primary care plans and medical homes in the private health care sector. Congress has formulated specific guidance for the development of the national immunization program in a few additional areas as well:

• In the initial buildup of the Section 317 infrastructure grants, Congress clearly intended that federal funds be used to improve access within high-risk communities by extending clinic hours and hiring staff to administer immunizations (U.S. House of Representatives, 1991; U.S. Senate, 1993, 1994).