their resources toward productive programmatic investments. However, this approach may not be sufficient in areas where states choose to distribute their own resources over a broad geographic area rather than concentrating them in areas of need where delivery systems may be weak and data collection difficult. State health agencies face difficult political obstacles when shifting public resources away from communities that have achieved high levels of coverage (sometimes with minimal state effort) so the resources can be targeted to areas where performance is poor. In such cases, the role of the federal government is to create incentives (e.g., ranking states on the basis of within-state disparities in coverage) or to provide targeted resources that enable states to do all they can to address the immunization needs of their most vulnerable citizens.

Question 6: What should be the role and financing level for CDC’s current program supporting state efforts to vaccinate adults and achieve the nation’s goals for influenza and pneumococcal vaccines? (Supported by Findings 3–3 and 3–5 in Chapter 3.)

Immunization coverage rates for adults are well below those achieved for childhood immunizations, although some progress in immunization was made in immunizing the adult population over age 65 during the 1990s. The Healthy People 2000 objective for influenza coverage levels was met for the noninstitutionalized elderly (individuals aged 65 and older) according to 1997 National Health Interview Survey (NHIS) data (see Table 3–6 in Chapter 3). The national average was 63 percent, up from 58 percent in 1995. According to 1997 data from the Behavioral Risk Factor Surveillance System (BRFSS), 45 states exceeded the goal of increasing influenza immunization levels to 60 percent among the elderly (CDC, 1998d). From 1995 to 1997, 48 states showed improvement in influenza vaccination rates for the elderly. The mean coverage level of states in 1997, 65.5 percent, was almost double the 1989 coverage level of 33 percent (CDC, 1998d). Nonetheless, in 1997, the percentage of adults aged 55–64 who received influenza vaccine ranged from 28.5 percent (Georgia) to 54.7 percent (Colorado), with a median of 38.2 percent. For persons aged 65–74, percentages ranged from 48.7 percent (Nevada) to 72.4 percent (Colorado), with a median of 63.6 percent. Among persons over age 75, percentages ranged from 51.7 percent (District of Columbia) to 82 percent (Arizona), with a median of 71.4 percent (Janes et al., 1999).

Pneumococcal immunization levels for the elderly are significantly lower than influenza immunization levels, even though Medicare covers the cost of this vaccine and its administration (Janes et al., 1999). The NHIS data show that only 42 percent of the noninstitutionalized elderly had ever received a pneumococcal vaccination by 1997 (see Table 3–6).

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