to strengthen immunization capacity and reduce disparities in child and adult coverage rates. The committee recommends that states increase their immunization budgets by adding $100 million over current spending levels, supplemented by an annual federal budget of $200 million to support state infrastructure efforts.

The committee believes state immunization programs could achieve stability and carry out their roles adequately through the adoption of a national finance strategy that involves investing a total of $1.5 billion in the first 5 years—an annual increase of $175 million over current spending levels—to support infrastructure efforts within the states. The federal budget figure is derived from three calculations: (1) annual state expenditure levels during the mid-1990s, (2) the level of spending necessary to provide additional resources to states with high levels of need without reducing current award levels for each state (known as a “hold harmless” provision), and (3) additional infrastructure requirements associated with adjusting to anticipated changes and increased complexity in the immunization schedule. The additional state contribution is necessary to reduce current disparities in state spending practices and to address future infrastructure needs in such areas as records management, development of appropriate performance measures and immunization registries, and outreach and education for adult vaccines. This increased budget could strengthen the state roles in immunization, with a special emphasis on infectious disease prevention and control, surveillance of vaccine coverage rates and safety, and programs to sustain and improve immunization coverage rates.

Different types of administrative support can be offered to the states to strengthen their immunization efforts. For example, federal reporting requirements for immunization grants should be reduced to six key areas that reflect the six fundamental roles of the national immunization system discussed in this report. In addition, grant budgetary cycles should be extended to 2 years to give states greater discretion and flexibility to plan and implement multiyear efforts in each area.

Recommendation 4: Congress should improve the targeting and stability of Section 317 immunization grant awards to the states by replacing the current discretionary grant award mechanism with formula grant legislation.

The formula should reflect a base level as well as factors related to each state’s need, capacity, and performance. A state match requirement should be introduced so that federal and state agencies share the total

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