2000, 67 percent of occupationally exposed workers received a hepatitis B vaccination in 1994, and 9 percent of men who had sex with men received this vaccination in 1997. NHIS data show that in 1995, 65 percent of persons aged 18–19, 54 percent of those aged 50–64, and 40 percent of those aged 65 and older had received a tetanus booster in the last 10 years (Singleton et al., forthcoming).

As with the monitoring of adult coverage levels, existing immunization finance programs tend to neglect the population aged 18–64. Adult immunizations are currently funded by a patchwork of public and private insurance that results in scattered immunization rate data, inconsistent insurance coverage among Americans, and a lack of collaborative roles and missions within the private and public health sectors.

Studies have shown that both influenza and pneumococcal vaccines are cost-effective. Yet federal funds that support adult immunization are a small fraction of the financial resources dedicated to childhood immunization. The main funding sources for adult immunization are Medicare, Section 317, and private insurance. States could spend Section 317 grants on vaccines and services for adults under age 65, but grantees have historically spent only a miniscule amount (estimated at about 2 percent) of their Section 317 funds on adult immunization. In addition, CDC did not authorize its grantees to use Section 317 funds in support of adult immunization until 1997 (information provided by CDC). Medicare has played a much larger role in adult immunization than that played by Section 317; it has covered pneumococcal vaccine since 1981 and influenza vaccine since 1993. In the future, with the dramatic rise of managed care and health maintenance organizations (HMOs) that emphasize preventive services, the committee believes adult immunizations are increasingly likely to be covered by private insurance. This trend provides an opportunity to raise awareness about the importance of immunization among health professionals who care for adults and to hold private plans and providers accountable for adult immunization performance measures.

As shown by the low coverage rates and low levels of funding, adult immunization is not a priority in the United States. Approximately 50,000 adult Americans still die each year from diseases for which both safe and effective vaccines exist, and yet as noted, only 2 percent of Section 317 funds have been dedicated to adult immunization (Poland and Miller, 2000). What is missing is a coordinated and comprehensive federal, state, and local strategy to improve adult immunization coverage levels. Health care providers are often less successful in providing age-appropriate immunizations as their clients grow from infancy through childhood to adolescence and adulthood. Immunization has not been the focus for practitioners who routinely care for adults that it has become for pediatric providers. Only rudimentary programs in state and local health depart-



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