zation services. Vaccines purchased with state or federal funds are increasingly delivered through private health care practices, except in states that continue to rely heavily upon public health clinics for primary health care services.

Completion of an immunization series requires multiple interactions with providers over a lengthy period of time, and determining the immunization status of an individual at any particular time can be difficult for both clients and health professionals. More than half of all infants and children aged 0 through 5, for example, are covered by private health insurance, but not all health plans include immunization coverage.8 In contrast, all Medicaid health plans include comprehensive immunization benefits within the Early and Periodic Screening, Diagnosis and Treatment program (as described in Chapter 3). SCHIP plans must also include immunizations as a basic benefit, comparable to Medicaid standards.

As noted earlier, however, the costs of achieving national immunization goals are not limited to the purchase and administration of vaccines. Other costs are incurred by public health agencies as part of their communitywide immunization programs, both universal and targeted (see Box 1–4). Disease prevention and control efforts, public information campaigns, provider education, reminder and recall systems, and immunization registry programs are all examples of universal programs whose costs are generally borne by the public sector. Immunization budgets are frequently combined with other public health programs at the state and local levels, supporting both core efforts and targeted initiatives. For individuals who do not have insurance or whose insurance does not cover immunization services, for example, targeted community assistance efforts are often required to assess their immunization status, and to connect individual children and adults with recommended immunization services and immunization records. Immunization assessment and referral services have also been added to Head Start centers, welfare assistance programs, and WIC clinics that provide nutritional supplement programs. Such efforts are commonly distributed across a broad spectrum of public and private agencies and are part of mission efforts within such fields as primary care, maternal and child health services, migrant health, and public health. As a result, their costs are generally not measured in estimating the expenses associated with immunization. Later in this report we examine whether the basic components of these costs can be identified, along with how they are allocated across different levels of government.

In summary, the role of the public health sector in immunization has shifted in the 1990s from a service-delivery function to one that is more directly involved with assessment, assurance, and policy development. This shift is consistent with trends in other public health programs, as described in earlier IOM reports (IOM, 1988, 1997). Yet federal immuniza-

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