23 urban areas (in addition to 5 urban grantees) as targets for new Immunization Action Plans.10 For each of the 28 target areas, an average immunization coverage rate was calculated with National Immunization Survey (NIS) data, and traditional public health providers and nontraditional community partners were encouraged to collaborate in program planning and implementation.

Several years later, the FY 1996 Senate Appropriations Committee (U.S. Senate, 1995) directed CDC to develop a strategy that would identify pockets of underimmunized children and help the states target resources to raise immunization coverage in these areas. Although NIP designated 11 major urban areas as pockets of need that would receive intensive follow-up and technical assistance, additional financial resources to support these efforts were not forthcoming in the state grant awards.11 In 1997, CDC instructed all grantees to place additional emphasis on identifying geographic subdivisions at high risk for underimmunization, measuring immunization coverage in these areas, and implementing measures designed to achieve high coverage among vulnerable groups.

CDC recommended three strategies for intensifying efforts to improve coverage rates in pockets-of-need areas: linkages between WIC and immunization services; Assessment, Feedback, Incentives, and eXchange of information (AFIX) interventions; and reminder-recall systems. State and local grantees were expected to implement these key strategies fully and to report progress in using them along with other initiatives, such as immunization registries, in areas identified as pockets of need.

The 1997 annual progress reports submitted to CDC included data provided by 58 grantees (information provided by CDC).12 About three-quarters of the respondents collected information on the key strategies recommended by CDC (WIC linkage, 79.3 percent; reminder-recall, 60.3 percent; and AFIX, 67.2 percent). However, only 11 grantees (19 percent) monitored the number of target WIC sites implementing high-risk protocols for immunization, an important strategy promoted by CDC as part of routine program management.13

In their progress reports, significant numbers of grantees indicated that they had redirected personnel (67.2 percent) or funds (55.2 percent) to work on pockets-of-need issues. The effects of these redirected efforts are not known, however. Neither CDC nor the state grantees have attempted to measure changes in coverage levels in the pockets of need against specific interventions. The prohibitive costs of small-area surveys are commonly cited as a major obstacle to such analysis.

In 1999 NVAC once again called on CDC and state and local immunization programs to focus resources on underimmunized populations. Immunization programs were encouraged to collaborate with WIC to assess each enrolled child’s immunization status, and state immunization

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