NOTES

1The diseases are: diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella, Hepatitis B, Haemophilus influenza type b, varicella, and rotavirus. Ten other vaccines have been recommended for use only in selected populations at high risk because of area of residence, age, medical condition, or risk behaviors. Vaccines are also available against rabies, typhoid, cholera, plague, and smallpox, but are not widely used today (Orenstein et al., in press).

2Defined as 3 or more doses of diphtheria, tetanus, pertussis (DTP), polio, and Hib vaccines, and one dose of measles, mumps, and rubella (MMR) vaccine.

3The IOM study was requested in U.S. Senate Report 105-300 to accompany S. 2440 (Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriations Bill), which directed the Centers for Disease Control and Prevention to contract with the Institute of Medicine to conduct an evaluation of the recent successes, resource needs, cost structure, and strategies for immunization efforts in the United States.

4The committee's final report, scheduled for publication in May 2000, will address six questions that frame the charge for this study: (1) an assessment of overall spending by all sources for immunization in the United States during the 1990s; (2) how new federal immunization funds were spent by the States and to what extent States maintained their own level of effort over the past 5 years; (3) current and future funding requirements for childhood immunization activities and how those requirements can be met through a combination of State funding, federal immunization funding, and funding available through the Children 's' Health Insurance Program; (4) how federal grant funds should be distributed among the States; (5) how funds should be targeted within States to reach high-risk populations without diminishing high levels of coverage in the overall population; and (6) the role and financing level for efforts by the Center for Disease Control and Prevention in supporting state immunization activities to vaccinate adults and achieve national goals for influenza and pneumococcal vaccines.

5A comprehensive history, of the evolution of federal immunization policy in the period 1955–1981 is included in a John Hopkins University doctoral dissertation by Patrick Vivier (Vivier, 1996).

6State reports indicate significant amounts of carryover funds: $119,553,727 (1994), $141,203,007 (1995), and $123,433,995 (1996). In each of these years states spent only slightly more than half of their total financial assistance Section 317 grant awards (see Table 2).

7In 1995, CDC transferred approximately $60 million from excess 317 vaccine into infrastructure and awarded it in September of that year. Although this transfer was made with congressional authority and approval, the arrival of the awards late in the grant year further exacerbated the carryover problem since states were required to obligate these funds before the end of the calendar year (Centers for Disease Control and Prevention, 1999c).

8Between 1992 and 1995, CDC awarded nearly all carryover in addition to, rather than in lieu of, newly appropriated funds, thus compounding the problem in grantee areas having difficulty expending funds efficiently. During these years CDC reports that the National Immunization Program was trying to resolve the carryover issue by encouraging states to continue to build and sustain the systems needed to raise immunization coverage levels with new funds while using the carryover funds for one-time expenses (Centers for Disease Control and Prevention, 1999c: 3).



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Preliminary Considerations Regarding Federal Investments in Vaccine Purchase and Immunization Services: Interim Report on Immunization Finance Policies and Practices NOTES 1The diseases are: diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, rubella, Hepatitis B, Haemophilus influenza type b, varicella, and rotavirus. Ten other vaccines have been recommended for use only in selected populations at high risk because of area of residence, age, medical condition, or risk behaviors. Vaccines are also available against rabies, typhoid, cholera, plague, and smallpox, but are not widely used today (Orenstein et al., in press). 2Defined as 3 or more doses of diphtheria, tetanus, pertussis (DTP), polio, and Hib vaccines, and one dose of measles, mumps, and rubella (MMR) vaccine. 3The IOM study was requested in U.S. Senate Report 105-300 to accompany S. 2440 (Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriations Bill), which directed the Centers for Disease Control and Prevention to contract with the Institute of Medicine to conduct an evaluation of the recent successes, resource needs, cost structure, and strategies for immunization efforts in the United States. 4The committee's final report, scheduled for publication in May 2000, will address six questions that frame the charge for this study: (1) an assessment of overall spending by all sources for immunization in the United States during the 1990s; (2) how new federal immunization funds were spent by the States and to what extent States maintained their own level of effort over the past 5 years; (3) current and future funding requirements for childhood immunization activities and how those requirements can be met through a combination of State funding, federal immunization funding, and funding available through the Children 's' Health Insurance Program; (4) how federal grant funds should be distributed among the States; (5) how funds should be targeted within States to reach high-risk populations without diminishing high levels of coverage in the overall population; and (6) the role and financing level for efforts by the Center for Disease Control and Prevention in supporting state immunization activities to vaccinate adults and achieve national goals for influenza and pneumococcal vaccines. 5A comprehensive history, of the evolution of federal immunization policy in the period 1955–1981 is included in a John Hopkins University doctoral dissertation by Patrick Vivier (Vivier, 1996). 6State reports indicate significant amounts of carryover funds: $119,553,727 (1994), $141,203,007 (1995), and $123,433,995 (1996). In each of these years states spent only slightly more than half of their total financial assistance Section 317 grant awards (see Table 2). 7In 1995, CDC transferred approximately $60 million from excess 317 vaccine into infrastructure and awarded it in September of that year. Although this transfer was made with congressional authority and approval, the arrival of the awards late in the grant year further exacerbated the carryover problem since states were required to obligate these funds before the end of the calendar year (Centers for Disease Control and Prevention, 1999c). 8Between 1992 and 1995, CDC awarded nearly all carryover in addition to, rather than in lieu of, newly appropriated funds, thus compounding the problem in grantee areas having difficulty expending funds efficiently. During these years CDC reports that the National Immunization Program was trying to resolve the carryover issue by encouraging states to continue to build and sustain the systems needed to raise immunization coverage levels with new funds while using the carryover funds for one-time expenses (Centers for Disease Control and Prevention, 1999c: 3).

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Preliminary Considerations Regarding Federal Investments in Vaccine Purchase and Immunization Services: Interim Report on Immunization Finance Policies and Practices 9The amount of funds available for infrastructure services within the Section 317 grants in 1997 and 1998 is less than half of what was appropriated in 1996. See Table 2. 10F.E. Thompson, 1998. Letter to DHHS Secretary Shalala. December 23. Washington, DC: Association of State and Territorial Health Officials. 11Institute of Medicine. 1994. Overcoming Barriers to Immunization. Washington, DC: National Academy Press. p. 3. 12See, for example, letter from the Association of State and Territorial Health Officials to Secretary Donna Shalala (Thompson, 1998): “The severe cuts (upwards of 60%) to infrastructure over the last two years have resulted in major cutbacks on the state level including: reductions in every aspect of programs, from development of materials to staffing of clinics; cancellations of contracts with WIC, private providers, community health centers, TANF, and community coalitions; severe reductions in registry development and maintenance; reductions in clinic hours and the delivery of shots; and cancellation of assessment programs, evaluation and surveillance improvements. In addition the severe cutbacks do not allow for states to plan and implement the institutionalization of vaccine delivery strategies that work…”. Washington, DC: Association of State and Territorial Health Officials. Proposed reductions in state efforts have also been described in materials provided by the CDC to the National Vaccine Advisory Committee (CDC, 1999d). 13See for example, S. Richardson, 1998, letter to state health officials. May 11. Washington, DC: Health Care Financing Administration.