for the recommended schedule of child and adult immunizations are important parts of the national immunization partnership; however, such efforts are not addressed in this report.10 Efforts to monitor vaccine safety and provide adequate compensation for adverse events related to vaccine use through special government trust funds represent an additional area of concern that lies beyond the framework for this study, although public concerns about the safety of vaccines have major implications regarding the level of resources necessary to sustain high immunization coverage rates.11

The six roles of the national immunization system are complex for three reasons. First, each encompasses an array of specific programs and functions (see Figure 1–7). Programs to improve immunization coverage rates, for example, include interventions to reduce vaccine costs, expand access to immunization services, address missed opportunities, improve documentation of immunization status, increase community demand for vaccinations, and establish requirements and incentives for providers. Likewise, the surveillance of immunization coverage rates may include a variety of tools and methods, including the National Immunization Survey, national surveillance studies, pocket-of-need assessment studies, regional and state immunization registries, and local-area surveillance studies that focus on specific populations.12

Second, the six roles of the national immunization system are not rigid or fixed, and certain other factors add to their complexity. Although they share common features, they are also elastic and decentralized, expressed in different ways over time within the broad array of public health efforts throughout the United States. A successful national immunization system requires that each role be present within each state, but their form, scope, and intensity will vary. For example, certain populations are easier to track than others, and the extent of monitoring efforts required will be proportional to the level of heterogeneity within the population and the complexity of the health service plans that serve their immunization needs. Likewise, the public costs of immunizing the first 10 percent of a large population, who often have private insurance and are motivated to request immunizations from their health care providers, are significantly lower than the costs of immunizing the final 10 percent, who rely fully on public assistance to cover their health care costs and vaccine purchases. The final 10 percent includes significantly larger numbers of individuals who are not routinely connected to health care service centers, who experience consistent disruptions in changes in residence and in health care coverage (and whose health records are consequently scattered across multiple sources), and who are socially isolated or distrustful of services that do not demonstrate a tangible or immediate health benefit. Targeted community assistance efforts are required to connect



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