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Background In the United States, the purchase of vaccines and the delivery of immunization services depend on a complex mix of public and private funding and services. Although children’s immunization coverage rates reached high levels during the past few decades, a measles epidemic in 1989–1991 drew attention to the continuing health threat from vaccine-preventable diseases if immunization rates fall. Following the measles epidemic, the federal government substantially increased grants to states for immunization program activities (immunization “infrastructure” grants) through what is known as the Section 317 program. This CDC-administered program, which began in 1963, also provides federal assistance to states for vaccine purchase. Vaccines for Children (VFC), a federal program implemented in 1994, added new funding to purchase vaccine for qualifying children, primarily those enrolled in Medicaid or without health insurance coverage for immunization. Other developments in the 1990s also affected the immunization system. New, more expensive vaccines were added to the recommended schedule of immunizations. VFC and new approaches to Medicaid encouraged greater reliance on health care providers in the private sector for the delivery of immunization services, while the growth of managed care contributed to fundamental changes in the larger health care delivery system. In the wake of these changes, state and local health departments had a smaller role in the direct provision of immunization services. They frequently took on a new role, however, that placed greater emphasis on monitoring indicators of community health status and service delivery
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(IOM, 1996, 1997), including assessing immunization coverage rates, and on responding to immunization and other specific health care needs of hard-to-reach populations. Although the states welcomed new federal immunization funding in the mid-1990s, many of them found it difficult to expend the sudden and significant increases in Section 317 immunization infrastructure awards during the one-year grant period. As a result, states “carried over” large amounts of these grant funds to subsequent years. By 1996, the U.S. Congress had cut back funding for Section 317 infrastructure grants, indicating its uncertainty that the states needed, or could manage, federal assistance in this area. In 1998, Congress asked that the Institute of Medicine (IOM) conduct a study of the Section 317 program and of broader questions regarding appropriate levels of effort to achieve national immunization goals. The IOM study committee met in 1999 and 2000 to collect relevant information and to develop a framework to guide its deliberations. In support of the study, a research team at the University of Michigan was commissioned to conduct a series of structured telephone interviews with immunization program officials in all 50 states regarding the effects of changes in federal policies and funding during the 1990s on the goals, priorities, and activities of state immunization programs (Freed et al., 2000). IOM staff and consultants developed eight case studies of public-sector immunization efforts in Alabama, Maine, Michigan, New Jersey, North Carolina, Texas, Washington, and Los Angeles and San Diego counties in California (Fairbrother et al., 2000b).1 Site visits to Detroit, Houston, Los Angeles, and Newark allowed for discussions with local providers and immunization program representatives that supplemented the case study materials. A workshop examined issues related to “pockets of need.” The committee also commissioned background papers on topics such as adult immunization, registries, measuring immunization coverage (Fairbrother et al., 2000a), and federal immunization policy (Johnson et al., 2000). Selected materials from the case study reports and commissioned papers were published in October 2000 in a supplement to the American Journal of Preventive Medicine. 1 Each case study is available electronically via the website of the National Academies Press: www.nap.edu/html/case_studies.
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