gram, to respond to unexpected circumstances and changing conditions that require enhanced efforts, and to prevent infectious disease transmission across state borders. These arrangements are traditionally divided into two categories: vaccine purchase and infrastructure support.

Vaccine Purchase. Federal assistance for state vaccine purchases and immunization programs is provided primarily through two funding streams: Section 317 of the Public Health Service Act, administered by the National Immunization Program within CDC, and the Vaccines for Children (VFC) program, administered jointly by CDC and the Health Care Financing Administration (HCFA). Through these two efforts, the federal government awarded more than $600 million in vaccine supplies to the states in fiscal year (FY) 1999, primarily for childhood vaccines. In addition, Medicare pays for preventive adult vaccines, which are financed primarily through Medicare payments to physicians. In 1998, HCFA paid Medicare providers $114 million for influenza and pneumococcal immunizations, primarily for adults over age 65.

The vast majority of states depend primarily on federal grants for the purchase of vaccines. Only 10 states rely on state funds for 30 percent or more of the public dollars spent to purchase vaccines. In almost half the states (24), state funds account for less than 10 percent of all publicly purchased vaccines. The remaining states (16) use state funds for between 10 and 30 percent of public vaccine purchases. State-level funds enable the purchase of vaccines for many underinsured children and adults (who are not eligible for federally financed vaccines), especially those who receive vaccines in local public health clinics. Fifteen states have adopted universal purchase policies, whereby they purchase vaccines for all children served by public clinics or participating providers, regardless of their insurance status.

The number of sites administering childhood or adult vaccines purchased with government funds increased dramatically over the past decade—from about 3,000 public health clinics and several hundred Medicaid health care providers in the 1980s to more than 50,000 public and private sites in 1999. The creation of VFC has been extraordinarily successful in encouraging large numbers of private health care professionals to administer vaccines to low-income children as part of their primary health care benefits. But this success in increasing the size and diversity of the vaccine delivery system has complicated the tasks of educating providers, assessing safety, documenting coverage rates, and assuring fairness in providing access to vaccines in public and private settings.

Immunization Infrastructure. Local, state, and federal public health agencies incur significant expense in exercising their responsibilities for



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