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HEADQUARTERS 
REGION 
Carolyn R.NeuwirthP,r ojecLte
ader  MarutaZitans, Program Specialist 
Michelle Adams, Program Analyst  Ann OConnor, Program Specialist  Department  of Health  and Human  Services 
OFFICE  OF

NSPECTOR  GENERAL

THE  ROLE  OF  THE  FEDERAL  MATERNAL 
AND  CHILD  HEALTH  BUREAU  IN 
PRESCHOOL  IMMUNIZATIONS 
OCTOBER  1993  OEI-06-91-01180
 EXECUTIVE  SUMMARY

PURPOSE 
To  examine  the  Public  Health  Service  (PHS)  Maternal  and  Child  Health  (MCH) 
Bureaus  efforts  to improve  preschool  immunizations. 
BACKGROUND 
Currently,  only 57 percent  of two-year-olds  are  appropriately  immunized  against 
vaccine-preventable  diseases  according  to  1991 prelimina~  data  from  34 State  MCH 
programs.  During  the  recent  measles  epidemics,  this age  group,  primarily  urban, 
inner-city  minority  children,  accounted  for  almost  half  of the  reported  cases.  These 
low preschool  immunization  rates  reflect  fragmented  efforts  to deliver  immunizations, 
the  high  cost  of vaccines,  and  poor  public  awareness.  Reaction  to this  situation  has 
prompted  government  agencies  to  expand  and  further  coordinate  efforts  to improve 
immunization  rates,  with the  Centers  for Disease  Control  and  Prevention  (CDC), 
Division  of Immunizations,  the  National  Vaccine  Program  Office  (NVPO),  and  the 
MCH  Bureau  being  among  the  players. 
In light  of continuing  low preschool  immunization  rates,  the  President  requested  a 
supplemental  appropriation  of $300 million  for FY  1993 and  proposed  the 
Comprehensive  Child  Immunization  Act  of 1993, a multi-year  initiative,  to  assure 
that  all children  in the  United  States  are  protected  against  vaccine-preventable 
infectious  disease  by their  second  birthday. 
Both  the  CDC,  Division  of Immunizations,  and  the  NVPO  have  singular  missions 
related  to the  prevention  and  control  of vaccine-preventable  diseases.  Toward  this 
purpose,  CDC  receives  approximately  99 percent  of the  Department  of Health  and 
Human  Services  funds  designated  for immunization-related  activities.  The  NVPO,  in 
its charge  to bring  coherence  to a fragmented  immunization  system,  chairs  the  Federal 
Interagency  Committee  on  Immunizations  (ICI).  The  ICI has  developed  a national 
immunization  action  plan  which  is intended  to coordinate  the  immunization  efforts  of 
diverse  government  agencies.  By contrast,  the  mission  of the  MCH  Bureau  is broader 
in scope  and  embraces  not  only the  critical  concern  for immunizations  but  also the 
development  of a comprehensive  health  care  system  for  all mothers  and  children. 
However,  the  MCH  Bureau  has  recently  been  given  specific  immunization 
responsibilities  through  legislation,  as well as through  its commitments  made  in the  ICI 
Action  Plan  to improve  preschool  immunizations. 
To  examine  the  Bureaus  specific  immunization  role,  we reviewed  relevant  literature 
and  legislation,  as well  as conducted  interviews  with  top  MCH  Bureau  and  other  PHS 
officials,  MCH  regional  program  consultants,  and  public  and  private  sector  experts 
involved  in immunizations.  Our  review  was conducted  prior  to the  announcement  of 
the  Presidents  new  initiatives  and  reflects  the  MCH  Bureaus  role  since  passage  of the 
i
 1989 Omnibus  Budget  Reconciliation  Act  (OBRA-89)  that  specified  national  health 
status  goals  including  immunization  rates.  Nevertheless,  this  report  illustrates  how the 
MCH  Bureau  could  contribute  to the  Presidents  initiatives. 
FINDINGS 
lhe MCH  Bureau Has Not Fully Capitalized  On I& Potential  To Guide and Diiect  State 
MCH  i?ogram  Eflorts  To Impve  Ihschool  Immun&ations. 
The  MCH  Bureau  has not  established  an explicit,  formal  immunization 
	
initiative  beyond  its emphasis  on comprehensive  health  care. 
The  MCH  Bureau  has  not  met  all its immunization  commitments  under  the  ICI 
	
Action  Plan. 
In particular,  the  MCH  Block  Grant  guidance  has not  been  modified  to direct 
State  plans  or activities  to focus  upon  improving  immunization  rates. 
Technical  assistance  has  focused  on the  development  of comprehensive 
	
health  care  and  has  not  placed  an  emphasis  on improving  immunization 
rates. 
Re@rem@s  R&ted  To %  Cdlkction  and Repating  Of StaLZImmunbtibn  Rakx 
Have  Been Dijicrd  To Imp-
RECOMMENDATIONS 
The  MCH  Bureau  should  play  an important,  if limited,  role  in improving  preschool 
immunization.  Toward  this purpose, 
PHS  should 
  Ensure  that  the  MCH  Bureau  strengthen  its guidance  and  direction  to State  MCH 
programs  to increase  preschool  immunization  rates  in addition  to other 
comprehensive  care  semices. 
Specifically,  the  MCH  Bureau  could: 
 
.	 direct  States  to use  MCH  Block  Grant  funds  to improve  preschool 
immunization  rates; 
develop  and  implement  a strategic  plan  with specific  assignments  and 
scheduled  action  steps  to strengthen  immunization  efforts,  especially 
for  preschoolers; 
ii  develop  a system  which  tracks  and  fully documents  progress  under 
the  MCHstrategic  immunization  plan;  and 
improve  guidance  and  technical  assistance  to increase  immunization 
rates. 
*	 Ensure  that  the  MCH  Bureau  and  the  CDC  closely  collaborate  to assure  a 
coordinated  effort  to improve  the  immunization  surveillance,  reporting  and 
deliveV  system. 
AGENCY  COMMENTS 
We  solicitaendd receivecdo rmnentsf romPHS on ourdraftr
eport.PHS concurred 
wthallourrecommendationasn disintheprocesso fimplementintghem.

See  Appendix  B for the  full text  of the  PHS  comments. 
... 
111
 TABLE  OF  CONTENTS 
PAGE

EXECUTIVE  SUMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7

  MCHBu~u  Efforts  to Improve  preschool  Immunizations  . . . . . . . . . . . . . .  7


Immunization  Reporting  Requirement  . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...10

APPENDICES

A.  Preliminary  Immunization  Data  . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l

B.  Agency  Comments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-1
 INTRODUCTION 
PURPOSE 
To  examine  the  Public  Health  Semite  (PHS)  Maternal  and  Child  Health  (MCI-I) 
Bureaus  efforts  to improve  preschool  immunizations. 
BACKGROUND 
Currently,  only 57 percent  of preschoolers  are  appropriately  immunized  according  to 
1991 preliminary  data  from  34 State  MCH  programsl.  This  rate  falls far  short  of the 
Year  2000 preschool  immunization  goal  of 90 percent2  (see  Appendix  A).  This 
discrepancy  underscores  the  United  States  poor  ranking  worldwide,  placing  17th in 
immunizing  children  against  vaccine-preventable  diseases3;  56th  in immunizing 
minority  children;  15th for polio  immunizations;  and  49th  for polio  immunizations  for 
nonwhite  populations  (National  Institute  of Child  Health  and  Human  Development 
1992).  Between  1989 and  1991, the  resurgence  of reported  measles  cases  was partially 
attributed  to  the  failure  to appropriately  immunize  preschoolers.  This  group,  primarily 
urban,  inner-city  minority  preschoolers,  accounted  for almost  half of these  vaccine-
preventable  occurrences.  Also,  of the  1990 measles  cases  among  preschoolers,  more 
than  one-third  of the  children  were  not  vaccinated  (Center  for the  Future  of Children 
1992). 
Barriers  to timely  immunizations,  especially  for preschoolers,  were  also brought  to 
national  attention  by the  1991 publication  of The Measles  Epidemic:  Problems, 
Barriers,  and  Recommendations  or The  White  Paper  (National  Vaccine  Advisory 
Council  1991).  The  National  Vaccine  Advisory  Council  (NVAC)  report  asserted  that 
the  measles  epidemic  indicated  a much  larger  issue:  the  inadequacy  of the  nations 
health  care  system  to  deliver  primary  and  preventive  health  care  sexvices. 
Immunizations,  besides  being  a responsible  preventive  health  measure,  are  also  a cost-
effective  approach  to reducing  future  health  care  spending.  An  estimated  $10-$14 
are  saved  in later  medical  costs  for  every  $1 spent  on early  childhood  immunizations.4 
Government  agencies  are  beginning  to  coordinate  efforts  to improve  preschool 
immunization  rates.  Recent  efforts  to improve  the  immunization  system  are  focusing 
on more  interactive  relationships  among  the  nations  health,  income,  housing, 
educational,  and  nutrition  programs. 
The  MCI-I Bureau  is One  of Manv Federal  Plavers  in Preschool  Immunizations 
The  MCH  Bureau,  part  of the  Health  Resources  and  Service  Administration  (HRSA) 
of the  PHS,  administers  the  Maternal  and  Child  Health  Sexvices Programs,  authorized 
by Title  V of the  Social  Security  Act.  The  mission  of the  Bureau  is to provide 
1
 national  leadership  to develop,  administer,  coordinate,  monitor  and  support  Federal 
policy  and  programs  to improve  the  health  of the  Nations  mothers  and  children. 
Federal  funds  are  available  to the  States,  through  the  Maternal  and  Child  Health 
Block  Grant,  for the  provision  or the  purchase  of a broad  range  of maternal  and  child 
health  services.  The  law sets  out  a number  of purposes  for which  the  States  are 
authorized  to expend  appropriated  MCH  Block  Grant  funds,  including  1) reducing 
infant  mortality;  2) increasing  the  availability  of prenatal,  delivery,  and  postpartum 
care  to low-income  women;  3) reducing  the  incidence  of preventable  and  handicapping 
conditions  among  low-income  children;  4) providing  medically  necessary  semices  to 
children  with  handicaps  or children  with  special  health  care  needs;  and  5) increasing 
the  number  of children  immunized  against  disease  and  receiving  health  assessments. 
Recent  amendments  through  the  1989 Omnibus  Budget  Reconciliation  Act  (OBRA-
89) have  specified  national  maternal  and  child health  status  goals  and  objectives  that 
should  be  attained  by the  States  through  reference  to the  Departments  Year  2000 
National  Health  Objectives.  The  law also  requires  State  reports  to determine 
whether  the  States  are  making  progress  in improving  the  health  status  of mothers  and 
children.  These  reports  are  to contain  information  and  data  that  is essential  for an 
effective  evaluation  of both  individual  State  MCH  Block  Grant  programs  and  the 
entire  Title  V authority.  States  are  required  to  annually  report  by class of individuals 
seined,  on the  number  of individuals  seined  under  Title  V; the  proportion  of such 
individuals  who  have  health  insurance;  the  types  of semices  provided;  and  the  amounts 
spent  on each  type  of service;  and  information  on the  status  of maternal  and  child 
health  in the  State,  which  includes  reporting  preschool  immunization  rates? 
Year 2000 Immunization  Goal 
The  Year  2000 objectives  identifj  immunization  and  control  of infectious  diseases  as

a high  priority.  The  MCH  Bureau  has  been  given  specific  immunization

responsibilities  in OBRA-89  to support  the  Year  2000 preschool  immunization  goal,

as well  as to report  preschool  immunization  rates.  The  MCH  Block  Grant  is one

available  resource  for  State  MCH  programs  to  support  immunization-related  activities.

For  Fiscal  Year  (FY)  1993, more  than  $557 million  were  disbursed  to MCH  Block

grantees.  The  proportion  of MCH  Block  Grant  funds  used  for immunization-related

activities  is at  State  discretion.

The  MCH  Bureau  is currently  integrating  the  data  reporting  requirements  into  their

more  traditional  role  of providing  comprehensive  health  setices.  Each  State  MCH

program  is required  to  annually  report  the  proportion  of appropriately  immunized

two-year-olds.  This  data  is then  compiled  by the  MCH  Bureau  and  submitted  to the

Congress,  as required  by OBRA-89.  -

Additionally,  the  MCH  Bureau  has  agreed  to  implement  several  action  steps  from  an

interagency  plan  which  was developed  to  coordinate  efforts  to improve  access  to

childhood  immunizations.  These  actions  are  described  on page  5.

2  The  Centers  for Disease  Control  and  Prevention.  Division  of Immunization,  Plavs a

Maior  Role  in Preschool  Immunizations

The  Centers  for  Disease  Control  and  Prevention,  Division  of Immunization  (hereafter

referred  to  as CDC),  is responsible  for leadership  and  guidance  in the  prevention  and

control  of preventable  childhood  diseases.  CDC  receives  99 percent  of HHS  funds

designated  for immunization-related  activities  and  its funding  levels have  significantly

increased  during  the  past  five years  (U.S.  Department  of Health  and  Human  Services

January  1992).  The  CDC  administers  the  Vaccination  Assistance  Act  of 1962, a

Federal  grant  program,  which  provides  financial  and  technical  assistance  to

supplement  State  and  local  health  department  efforts  to provide  immunizations.  FY

1993 funding  was more  than  $349 million,  approximately  3.5 times  greater  than  the  FY

1988 allocation  (U.S.  Department  of Health  and  Human  Semites  May  1992).

CDC  is engaged  in a myriad  of immunization-related  activities,  including:  1) assisting

States  to  implement  The  White  Paper  recommendations  to improve  the  diagnosis,

delivery,  and  efficacy  of childhood  immunizations;  2) conducting  a national  public

information  campaign  on preschool  immunizations;  3) expanding  efforts  to incorporate

hepatitis  B into  routine  infant  immunization  programs;  4) purchasing  additional

vaccines  to improve  age-appropriate  immunization  levels;  5) expanding  support  for

State-based  immunization  programs;  and  6) stockpiling  Hib,  hepatitis  B, and  accellur

DPT.  Additional  CDC  immunization-related  activities  include:

.	 Collecting  preschool  immunization  data  through  the  use  of retrospective  studies 
of school-entry  immunization  records.  Guidelines  for Assessing  Vaccination 
Levels  of the  2-year-old  Population  in a Clinic Setting  was published  in 
October  1992 and  distributed  to all State  CDC  grantees,  plus members  of the 
Association  of Maternal  and  Child  Health  Programs  (U.S.  Department  of 
Health  and  Human  Services/Public  Health  Service  October  1992). 
Conducting  demonstration  projects,  e.g.,  1) coordinating  efforts  with  the  Special 
	
Supplemental  Food  Program  for Women,  Infants,  and  Children  (WIC)  and  with 
Aid  to Families  with  Dependent  Children  (/U?DC)  to improve  recipients 
immunization  levels;  2) providing  free  immunizations  for children  up  to the  age 
of tsvo who  live in communities  with  a high proportion  of low-income 
individuals  and  3) conducting  awareness  campaigns  to both  identify  these 
children  and  inform  parents  (or  guardians)  about  this  service. 
Implementing  an  Infant  Immunization  Initiative  (I-3)  to improve  immunization 
	
levels  among  very young  children.  I-3 places  a special  emphasis  on assessment 
and  operational  research.  Major  issues  concern  the  magnitude  of the  problem, 
as well as identifying  attitudinal  and  structural  barriers.  In the  summer  of 1992, 
more  than  $45 million  supplemental  funds  were  distributed  among  63 State 
immunization  grantees,  plus  twenty-four  selected  urban  areas,  to  develop  local 
Immunization  Action  Plans  (I./W).  These  plans  focus  on strengthening  the 
3  vaccine  delivery  infrastructure  for preschool  immunizations.  The  IAPs  also 
focus  on State  assessment  activities  and  informational/education  projects  for 
improving  preschool  immunizations. 
Additional  Key Players  in HHS  and  Other  Government  &  encks 
l%e National  Vaccine Program Office 
The  National  Vaccine  Program  Office  (NVPO)  was established  in 19866 and  is a part 
of the  Office  of the  Assistant  Secretary  for Health  (OASH)/  PHS/  HHS.  Its mission  is 
to bring  coherence  to a fragmented  immunization  system.  Designated  as the  national 
vaccine  policy  authority,  its FY  1993 budget  of $3 million  reflects  a $5 million  dollar 
decrease  from  FY  1992.  However,  this  difference  was redistributed  between  CDC  and 
the  National  Institutes  of Health  (NIH)  for expanded  vaccine  activities  (U.S. 
Department  of Health  and  Human  Services  January  1992). 
The  NVPO  coordinates  and  provides  direction  for  research  conducted  by NIH,  CDC, 
the  Office  of Biologics  Research  and  Review  of the  Food  and  Drug  Administration 
(FDA),  the  Department  of Defense  (DOD),  and  the  Agency  for  International 
Development.  Other  responsibilities  of the  NVPO  include  1) development  of an 
annual  National  Vaccine  Plan  (NVP)7  and  2) implementation  of some  of the  National 
Vaccine  Iniurv  Com~ensation  Pro~ams  (NVICP)8  statutory  provisions.  Committees 
directly  related  to the  NVPO  are  1) the  National  Vaccine  AdvisoV  Committee  and  2) 
the  National  Vaccine  Program  Interagency  Group.9 
Federal Interagency Committee  on Immunization  (ICI) 
The  ICI was formed  in early  1991 and  is chaired  by the  NVPO  Director.  The 
committee  has  developed  a comprehensive  Action  Plan  released  May  11, 1992.  The 
plan  includes  120 action  steps  to be  implemented  between  1991 and  1995.  Although  it 
does  not  have  oversight  authority  to enforce  the  Action  Plan,  ICI  monitors  progress 
under  the  plan  through  regular  reports  to the  Assistant  Secretary  for Health. 
ICI  representatives  from  HHS  are  the  NVPO,  CDC,  HRSA  (which  includes  the  MCH 
Bureau),  Indian  Health  Service  (IHS),  the  Assistant  Secretary  for Planning  and 
Evaluation,  the  Office  of Health  Planning  and  Evaluation,  the  Office  of Minority 
Health  (OMH),  Office  of the  Surgeon  General  (OSG),  NIH,  Administration  for 
Children  and  Families  (ACF),  and  the  Health  Care  Financing  Administration  (HCFA). 
Other  government  agencies  represented  are  the  Department  of Agriculture  (USDA), 
the  Department  of Education  (DoE),  and  the  Department  of Housing  and  Urban 
Development  (HUD),  as well as a liaison  from  the  NVAC.  Directly  responsible  for 
implementing  the  Action  Plan  are  HRSA  (which  includes  the  MCH  Bureau),  CDC, 
ACF,  HCF~  IHS,  NVPO,  OMH,  OSG,  NIH,  DoE,  HUD,  and  USDA. 
MCH  Bureau  immunization  efforts  under  the  Action  Plan  include:  1) providing 
technical  assistance  to  support  State  and  local  health  department  immunization 
4  programs;  2) coordinating  with  the  CDC  and  State  health  officers  to conduct  regional

workshops  for  State  agencies  involved  in activities  to improve  preschool

immunizations;  3) working  with  the  Healthy  Start  program  on immunization  activities,

including  a national  public  education  campaignlO;  4) modi&ing  MCH  Block  Grant

guidance,  as well as State  annual  reporting  requirements,  to specifically  focus  on plans

and  activities  to improve  State  immunization  status;  5) working  with  the  Association  of

Maternal  and  Child  Health  Programs  (AMCHP)  network  and  Department  of Health

and  Human  Service  (HHS)  regional  office  staff  to determine  barriers  to improving

immunization  status;  6) disseminating  Standards  for Pediatric  Immunization

Practices;  7) working  with  designated  State  MCH  Program  directors  to identi~

barriers  to  developing  a partnership  with  health  care  provider  organizations;  8)

reviewing  current  approaches  for increased  provider  participation  to deliver

immunizations;  9) reviewing  MCH  Block  Grant  applications  to identify  effective

immunization  program  activities;  10) working  with the  National  Conference  of State

Legislatures  (NCSL)  to increase  awareness  of immunization  status  and  problems  and

possible  legislative  remedies;  and  11) encouraging  State  and  local  governments  to

mandate  appropriate  immunizations  prior  to enrolling  children  in licensed  day care

centers  (Interagency  Committee  on Immunizations  1992).

Barriers  to  Immunizimz  preschoolers

Several  barriers  to immunizing  preschoolers  have  been  documented  (Orenstein,

Atkinson,  Mason,  and  Bernier  199Q National  Vaccine  Advisory  Committee  January

1991).  First,  there  are  funding  and/or  logistical  barriers,  including  limited  clinic

staffing  and  service  hours,  as well as inaccessible  clinic locations.  Second,  there  are

policy  barriers,  such  as appointment-only  service  systems  which  require  prior  physical

examinations,  physician  referrals,  or enrollment  in comprehensive  care  well-baby

clinics, and  financial  screening  and/or  charging  fees  to administer  vaccines.  Third,

perceptual  barriers,  such  as fear  of adverse  reactions  and  low parental  priority  to

immunize  may  also  impede  immunization.  Other  factors  mentioned  are  low

educational  attainment  of either  parent,  large  family size, low socioeconomic  status,

nonwhite  identity,  reliance  on public  clinics as the  immunization  source,  young

parental  age,  single  parenthood,  lack  of prenatal  care,  and  late  start  of the

immunization  series.

To  address  these  barriers,  The  White  Paper  recommends:  1) making  immunization

services  more  readily  available;  2) improving  the  management  of immunization

delive~,  3) creating  an  ongoing  measurement  of childrens  immunization  status;  4)

implementing  a two-dose  schedule  for measles,  mumps,  and  rubella  (MMR);  5)

establishing  a revolving  fund  for  outbreak  control;  6) gathering  more  information

about  the  various  vaccine-preventable  diseases,  and  7) planning  a future  strategy  to

improve  vaccine  delive~.

5
 Presidential  Initiatives 
In light of continuing  low immunization  rates,  the  President  requested  a supplemental 
appropriation  for FY  1993 and  sent  the  Comprehensive  Child  Immunization  Act  of 
1993 to the  Congress  on March  30, 1993.  The  goal  is to assure  that  all children  in 
the  United  States  are  protected  against  vaccine-preventable  infectious  diseases  by their 
second  birthday.  This  legislation  introduced  a new collaborative  partnership  among 
parents  and  guardians;  health  care  providers;  vaccine  manufacturers;  and  Federal, 
State  and  local  governments  to immunize  preschoolers. 
METHOIXMXIGY 
Several  steps  were  involved  in determining  what  Federal  MCH  Bureau  and  MCH 
regional  office  plans,  guidance,  technical  assistance,  monitoring  mechanisms,  and 
collaborative  agreements  are  in place  to improve  preschool  immunizations.  Our 
methodology  included:  1) reviewing  relevant  literature  and  legislation;  2) consulting 
either  through  either  telephone  or on-site  intemiews  with  public  and  private  sector 
experts  involved  in immunizations;  3) conducting  in-depth  interviews  with  top  MCH 
Bureau  management  and  staff  involved  with immunizations,  as well as with  other  top 
PHS  officials;  4) conducting  telephone  interviews  with  all MCH  regional  program 
consultants;  and  5) doing  a content  analysis  of all documentation  provided  by the 
MCI-I Bureau  and  MCH  regional  program  consultants,  which  included  reviewers 
comments  on the  FY  1993 MCH  Block  Grant  applications.  Our  review  was conducted 
prior  to the  announcement  of the  Presidents  new initiative  and  reflects  the  MCH 
Bureaus  role  since  passage  of OBRA-89  that  specified  national  health  status  goals 
including  immunization  rates.  Nevertheless,  this  report  illustrates  how the  MCH 
Bureau  could  contribute  to the  Presidents  initiatives. 
6
 FINDINGS

THE  MCH  BUREAU  HAS  NOT  FULLY  CAPITALIZED  ON  ITS POTENTfAL 
TO  GUIDE  AND  DIRECI  STATE  MCH  PROGRAM  EFFORTS  TO  IMPROVE 
PRESCHOOL  IMMWWZATIONS. 
b	 lhe  AUCHBureau has not established  an expw  fond  immunimtion  initiative 
beyond  its emphash  on comprehensive  heakih care. 
The  MCH  Bureau  has  some  immunization  projects  underway.  For  example,  the 
Bureau  has  specifically  contracted  for two surveys that  will be  used  to identify  State 
MCH  program  immunization  activities.  These  include:  1) the  AMCHPS  survey of 
State  Title  V program  activities,  which  include  immunization-related  activitiesll  and 
2) CityMatCHs  survey  of 177 urban  health  departments  about  their  immunization 
sexvices12.  Also,  through  the  cooperative  agreement  with  NCS~  several 
immunization-related  publications  have  been  produced.  The  NCSL  also  held  a 
roundtable  discussion  at  its 1992 annual  meeting  which  involved  immunizations. 
Nevertheless,  the  Bureau,  in its effort  to emphasize  development  of comprehensive 
systems  of care  for  children,  has  not  established  an explicit,  formal  immunization 
initiative  to focus  priorities  and  efforts  for expanded  immunization  responsibilities. 
The  Bureau  has  not  developed  an immunization  plan  or strategy  beyond  its activities 
included  in the  ICI Action  Plan,  giving the  impression  that  improving  preschool 
immunizations  is not  a program  priority. 
The  MCH  Bureau  has  a fragmented  approach  to delegating  responsibilities  for 
immunization-related  activities,  with these  being  split between  MCH  Bureau  divisions. 
One  division  deals  with  program  support  and  another  focuses  on data  collection  and 
analysis.  We  found  a lack  of coordination  and  communication  among  these  different 
programmatic  divisions. 
There  are  a number  of potential  opportunities  the  MCH  Bureau  can  use  to enhance 
immunization  efforts.  For  example,  the  Bureau  has  entered  into  a number  of 
cooperative  agreements  for  the  purpose  of sharing  information  and  collaborating  with 
organizations  representing  health  policymakers  at  all levels  of the  private  and  public 
sectors.  Although  broad  in scope,  these  cooperative  agreements,  collectively  known  as 
the  Partnership  for  Information  and  Communication  (PIC),  in the  future  could 
incorporate  specific  immunization  activities.13 
Purported  efforts  to  implement  the  MCH  Bureaus  portion  of the  Action  Plan  were 
outlined  in a September  1992 progress  report  to the  ICI.  However,  the  MCH  Bureau 
could  not  document  some  of these  activities,  particularly  for  the  two action  steps 
7  involving  the  BlockGrant.  First,  MCH  Block  Grant  guidance  has  not been  modified 
to specifically  direct  State  plans  or activities  to focus upon  the  improvement  of 
immunization  rates  beyond  immunizations  as a part  of the  primary  care  system. 
Secondly,  reviewers  of the  Block  Grant  have  not  been  instructed  to identify  effective 
immunization  program  activities. 
Additionally,  the  MCH  Bureau  agreed  to conduct  regional  preschool  immunization 
workshops  for State  agencies  in conjunction  with CDC.  The  MCH  Bureau  now 
reports  that  alternative  means  of informing  and  providing  technical  assistance  are 
being  used,  since  initial  funding  was not  forthcoming.  These  alternative  actions  have 
been  earned  out  in less than  half  of the  MCH  regions  (four  regions).  Activities 
include  conducting  a two-day  statewide  conference  in one  of the  regions;  serving  on a 
State  committeetodevelopanimmunizatiopnl an,aswellasaccompanyingC
DC
regionaslt afdfu ringsitev isittso immunizatiognr anteeisn twooftheregionsa;n
 d

workingwithStatest odeveloptheirC I.lCIrnrnunizatAicotni onPlansi,n additiotno
 

workingon otherCDC immunizatiopnl
 ansinanotherregion.

w	 Technical awiwmce  has f~ed  on the developnumt  of comprehensive  heakkhcare 
and has not pkhced an ernphasir on impmving  immunkation  mtes. 
Technical  assistance  regarding  immunizations  has been  minimal.  For  example,  the

MCH  Bureau  reported  that  telephone  contact  is the  way they  most  often  provide

technical  assistance  to regional  offices  on preschool  immunizations.  This  contact  is

usually  done  in response  to questions  on immunization  schedules.  MCH  regional

offices  also  reported  infrequent  and  primarily  informal  contact  with the  MCH  Bureau

for technical  assistance  on immunization-related  issues.  The  MCH  Bureau  has

attempted  to  address  specific  issues  on an individual  basis through  a memo  to the

requesting  regional  office.  Regionwide  immunization  memos  are  also distributed,  but

in the  past,  have  primarily  focused  on the  developmentof Head  Start  immunization

policies.

The  MCH  regional  offices  also  reported  limited  technical  assistance  to the  States,

relying  primarily  on telephone  and  written  communications.  Restricted  travel  funds

are  said  to constrain  many  technical  assistance  activities.  Regional  immunization

technical  assistance  has  almost  exclusively  focused  on Head  Start.  Between  1991-1992,

all MCH  regional  offices  reported  either  on-site  or telephone  Head  Start

immunization  contacts,  ranging  from  as few as four  to  as many  as 69.  However,  it

should  be  noted  that  the  interagency  Head  Start  training  and  technical  assistance

agreement  supporting  these  activities  expired  on September  30, 1992.

With  respect  to the  immunization  reporting  requirement,  seven  of ten  MCH  regional

offices  are  providing  technical  assistance.  Of these  seven,  three  regional  offices  met

with  key State  MCH  persons  for  pre-application  technical  assistance;  one  identified

consultants  for  State-level  meetings;  three  held  some  type  of conference  for State

agencies  involved  in immunizations;  one  used  conference  calls to the  States;  and  five

provided  technical  assistance  via telephone,  but  only upon  request.  As for  technical

8  assistance  to help  States  focus  plans  or activities  to improve  immunization  status,  only

two of ten  MCH  regional  ofllces  reported  providing  any technical  assistance.

REQUREMHWS  RELATED  TO  THE  COLLE(HION  AND  REPORTING  OF

STATE  MMUNIZATION  RATES  HAVE  BEEN  DIFFICULT  TO  IMPLEMENT.

The  OBRA-89  requirement  for State  MCH  programs  to report  preschool

immunization  rates  duplicates  the  extensive,  ongoing  CDC  efforts  to collect  national

preschool  immunization  data.  All CDC  immunization  grantees,  which  includes  all

States,  are  required  to conduct  retrospective  surveys  of school-ent~  immunization

records.  CDC  also  encourages  grantees  to conduct  clinical  assessments  of preschool

immunization  rates,  using recently  published  methodological  guidelines.

However,  the  State  MCH  programs  are  required  to report  preschool  immunization

rates.  Toward  this end,  the  MCH  Bureau  has  contracted  with  the  Public  Health

Foundation  (PHF)  to  assess  States  capacity  to collect,  process,  analyze,  and  report

data  for  MCH  programs,  which  includes  immunization  data.  PHFs  Project  CAN-DO

(The  Project  for  Capacity  Assessment  and  Needs  Determination  for OBRA  89) will

include  a self-assessment  of each  States  current  data  capacity,  along  with  descriptions

of current  data  utilization  for resource  allocation,  evaluation  and  planning  purposes.

A workbook  will be  developed  and  used  by the  MCH  Bureau  and  MCH  regional

offices  to prioritize  areas  for future  technical  assessment.

Currently,  the  MCH  Bureau  has  only included  minimal  reporting  guidance  in its Block

Grant  packet  developed  to assist  States  with  their  grant  applications  and  amual

reports.  Only in the  packets  appendices  are  three  cursory  reporting  references

mentioned  -- the  probable  source  of data  (i.e., State  program  data),  the  statutory

citation  (i.e., Section  506...),  and  the  program  component  in which  to report  the

information  (i.e., program  components  A and  B).

Within  MCH  regional  offices,  nine  out  of 10 said these  guidance  packets  were  their 
only source  of instruction  on how to  assist  States  with  the  immunization  reporting 
requirement.  The  remaining  regional  office  could  not  recall  any specific  guidance 
being  given  at  all.  When  asked  about  training  in this  area,  six out  of ten  MCH 
regional  offices  mentioned  they  had  attended  a national  data  conference  held  in 
January  1992 addressing  problems  related  to the  OBRA-89  reporting  requirements. 
Of these  six, only one  received  any other  training  related  to this  area. 
Overall,  very  little  systematic  assistance  has been  provided  to States  to help  ensure  the 
accuracy,  reliability,  and  comparability  of data  on State  immunization  rates. 
9
 RECOMMENDATIONS

All resources  in HHS  which  can  contribute  to achieving  increased  immunization  levels 
in children  should  support  the  Presidents  initiatives.  The  MCH  Bureaus  mission  is to 
ensure  a comprehensive  health  care  system  for all mothers  and  children,  and 
immunization  is a cornerstone  of such  a system.  While  the  MCH  Bureau  operates 
under  block  grant  restrictions  with  limited  resources,  steps  can  be  taken  to  ensure  the 
Bureaus  full contribution  to preschool  immunization  efforts  and  to the  Presidents 
goal  of immunizing  all two-year-olds.  The  MCH  Bureau  should  provide  leadership, 
direction,  guidance,  and  technical  assistance  for preschool  immunizations  to State 
MCH  programs. 
PHS  should: 
	 Ensure  that  the  MCH  Bureau  strengthen  its guidance  and  direction  to State 
MCH  programs  to increase  preschool  immunization  rates  in addition  to other 
comprehensive  care  semices. 
.  Specifically,  the  MCH  Bureau  could: 
direct  States  to use MCH  Block  Grant  funds  to improve  preschool 
immunization  rates.  States  should  compare  current  rates  with  the 
Year  2000 immunization  goal  of 90 percent,  as specified  in the 
MCH  Annual  Report  guidance  material.  MCH  Block  Grant 
applicants  should  use  this information  to  develop  an  action  plan  to 
reach  and/or  maintain  preschool  immunization  rates  of at least  90 
percent.  Their  progress  could  then  be  monitored  through  the  Annual 
Report  review  process.  States  should  also include  other  relevant 
information  collected  from  MCH/CDC  support  sumeys. 
.	 develop  and  implement  a strategic  plan  with  specific  assignments  and 
scheduled  action  steps  to strengthen  immunization  efforts,  especially 
for  preschoolers.  The  strategic  plan  should  1) incorporate  all of the 
Bureaus  ICI Action  Plan  commitments;  2) identi&  specific  Bureau 
staff  responsible  for  each  action  item;  3) specify  the  frequency  and/or 
time  table  for  each  action  item;  and  4) identify  MCH  Bureau  staff  as 
liaison(s)  with  ICI  and  CDC. 
develop  a system  which  tracks  and  fully documents  progress  under  the

MCH  strategic  immunization  plan.  Equally  important  to developing  a

strategic  plan  is to  ensure  that  the  plan  is being  implemented.  The

tracking  system  would  be  a mechanism  to  achieve  this  goal.

Complete  documentation  for  all completed  items  should  be

maintained.

10
 .  improve  guidance  and  technical  assistance  to increase  immunization 
rates.  Encourage  MCH  regional  offices to  develop  regional  and 
State-level  task  forces  to emphasize  common  goals,  especially 
improving  preschool  immunizations.  MCI-I officials  should 
reciprocally  participate  with  other  agencies  involved  with 
immunization  in such  activities  as reviewing  grants,  annual  reports, 
and  demonstration  project  applications. 
	 Ensure  that  the  MCH  Bureau  and  the  CDC  closely collaborate  to assure  a 
coordinated  effort  to improve  the  immunization  surveillance,  reporting  and 
delivery  system. 
.	 Data  collection  of preschool  immunization  rates  is already  being  done 
by CDC  immunization  grantees.  The  MCH  Bureau  should  actively 
collaborate  with  the  CDC  regarding  the  collection,  utilization,  and 
reporting  of preschool  immunization  data.  MCH  data  needs  should  be 
conveyed  to CDC  on an ongoing  basis. 
.	 The  Presidents  initiative  continues  to support  rebuilding  the 
infrastructure.  CDCS local  immunization  action  plans  (IA.Ps) provide 
support  to communities  for improving  their  vaccine  delivexy system. 
To  ensure  coordinated  planning,  the  IAPs  call for enlisting  the  active 
participation  of a States  primary  care  association  and  similar  groups 
involved  in primary  care.  The  MCH  Bureau  should  collaborate  with 
the  CDC  to assure  that  all State  MCH  programs  are  actively  involved 
in the  development  and  implementation  of the  IAPs. 
SUMMARY  OF  AGENCY  COMMENTS  AND  OIG  RESPONSE 
We  received  comments  from  PHS  on the  draft  report.  The  complete  text  of the  PHS 
comments  are  contained  in Appendix  B.  PHS  concurred  with  the  two OIG 
recommendations  shown  above  and  is in the  process  of implementing  them. 
It should  be  noted  we have  excluded  the  recommendation  contained  in the  draft 
report  about  PHS  technical  assistance  for  immunizations  to ACFS Head  Start 
program  and  its grantees.  ACF  has  decided  to coordinate  its health  technical 
assistance  activities  for  Head  Start  through  the  same  mechanisms  they  use  to deliver 
technical  assistance  for education,  social  services,  and  parents.  However,  PHS  has 
expressed  a willingness  to provide  technical  assistance  to the  Head  Start  program  in 
regard  to public  health  matters  if requested  in the  future  by ACF. 
11
 EN DNOTES

1.The first State  MCH  Annual  Reports  requiring  data  on preschool  immunizations 
were  reviewed  in September  1992.  The  mean  value  of 57 percent  excludes  the 
territories  of American  Samoa,  Northern  Mariana  Islands,  Federated  States  of 
Micronesia,  Guam,  Marshall  Islands,  Paulau  Islands,  and  the  Virgin  Islands.  Of the 
territories,  only one  provided  data,  reporting  a preschool  immunization  rate  of 99 
percent  (see  Appendix  A). 
2.  The  Maternal  and  Child  Health  Program  has  adopted  28 goals  derived  from,  or 
consistent  with,  Healthv  Peo~le  2000: National  Health  Promotion  and  Disease 
Prevention  Objectives.  MCH  goal  #10  is to increase  preschool  immunizations  to at 
least  90 percent. 
3.  As recommended  by PHSS Immunization  Practices  Advisory  Committee  (ACIP), 
preschool  immunizations  should  include:  1) Diptheria/Pertussisnetanus  [DPTJ;  2) 
Polio  -- live oral  polio  drops  [OPVl  or  [Inactivated]  polio  vaccine  shots  [IPVJ; 3) 
Measles/Mumps/  Rubella  [MMR];  4) Hemophilus  Conjugate  Vaccine  [HIB];  and  5) 
Hepatitis  B Vaccine  [HBVJ. 
4.  Some  of the  various  estimates  of the  ratio  of receiving  immunizations  to the 
reduction  of future  health  care  costs  are  $1:10  (National  Institute  of Child  Health  and 
Development  1992); $1:11.90  (Southwest,  an Aetna  Plan  1993); and  $1:14  (U.S. 
General  Accounting  Office  June  1992). 
5. On  a State-wide  basis,  OBRA-89  requires  information  about  the  following  indicators 
of the  status  of maternal  and  child  health  in each  State:  1) the  rate  of maternal 
mortality,  neonatal  death,  perinatal  death,  the  number  of children  with  chronic 
illness/type  of illness;  2) the  proportion  of infants  born  with fetal  alcohol  syndrome;  3) 
the  proportion  of women  who  do not  receive  prenatal  care  during  the  first  trimester  of 
pregnancy  and  4) the  proportion  of children,  who  at their  second  birthday,  have  been 
vaccinated  against  each  of measles,  mumps,  rubella,  polio,  diptheria,  tetanus,  pertussis, 
Hi% meningitis,  and  hepatitis  B [Section  6504 (a)(2)(B)(ii)(I-VIII)]. 
6.  The  National  Vaccine  Program  was authorized  in 1986 through  P.L.  99-66, Title 
XXI  of the  Public  Health  Services  Act,  Subtitle  1, Sections  300aal  - 300aa4. 
7.  The  purpose  of the  NVPO  annual  National  Vaccine  Plan  is to set  priorities 
related  to vaccine  development  and  distribution,  indicate  ways to maximize  resources, 
and  describe  collaborative  approaches  among  involved  agencies  and  departments. 
8.  The  National  Vaccine  Injuxy Compensation  Program  (NVICP)  is separate  from  the 
National  Vaccine  Program  (NW).  The  NVICP  is responsible  for  compensations  paid 
for  a vaccine-related  injury  or death.  The  Office  of Evaluation  and  Inspections,  Office 
12
 of Inspector  General,  Department  of Health  and  Human  Services  is currently  studying

the  NVICP  (The  National  Vaccine  Injury  Compensation  Program:  A Review,  OEI-

02-91-01460).  However,  the  NVPO  is involved  in the  development  of public

awareness  materials  concerning  risks associated  with immunizations;  collection  and

analysis  of data  about  adverse  vaccine-rela+ed  events;  and  oversight  of studies

concerning  childhood  vaccines  and  subsequent  adverse  reactions.

9.  The  National  Vaccine  Adviso~  Committee  (NVAC)  advises  the  NVPO  Director 
on all aspects  of the  program.  It is comprised  of 15 voting  members,  including  the 
chair,  and  5 nonvoting  members.  The  15 voting  members  represent  individuals  from 
such  areas  as vaccine  research,  manufacturers  of vaccines,  physicians,  members  of 
parent  organizations  concerned  with immunizations,  representatives  of State/local 
health  agencies  or public  health  organizations.  The  five nonvoting  members  represent 
the  Director  of the  NIH;  the  Commissioner,  FDA,  the  Director,  CDC;  the  Agency  for 
International  Development;  and  the  DOD. 
The  National  Vaccine  Program  Interagency  Group  (IAG)  makes  recommendations 
regarding  national  vaccine  policy and  operational  issues  to the  Assistant  Secretaq  for 
Health.  The  IAG  is comprised  of senior  representatives  from  the  Agency  for 
International  Development,  CDC,  DOD  (who  are  responsible  for immunizing  military 
persomel),  Food  and  Drug  Administration,  and  the  NIH. 
10.  As of October  1, 1992, the  Healthy  Start  Program  became  a part  of the  MCH 
Bureau.  The  Healthy  Start  Initiative  is a demonstration  project  in which  15 urban  and 
rural  communities  with infant  mortality  rates  of at least  1.5 times  the  national  average 
are  targeted  for Federal  funding.  In May  1992, a national  public  information  and 
education  campaign  was begun. 
11.  The  Association  for Maternal  and  Child  Health  Programs  (AMCHP)  conducted  a 
survey  of selected  preventive  and  primary  care  semices  for children  and  adolescents 
supported  through  each  states  Title  V program  during  FY  1991.  One  section  of the 
survey  asks specific  questions  about  immunizations  services,  which  include  current 
policies,  tracking,  coordination  with  other  agencies,  and  perceived  barriers  to full 
immunizations. 
12.  CityMatCH  conducted  a survey  of  177 urban  health  departments  in areas  with  a 
population  greater  than  100,000.  They  are  asking  about  such immunization  services  as 
administration  of vaccines;  purchase  and  distribution  of vaccines;  outreach  and 
education;  barriers  to  age-appropriate  immunizations;  activities  to assure  age-
appropriate  immunizations;  and  innovative  approaches. 
13. The  Partnership  for  Information  and  Communication  (PIC)  cooperative

agreements  include  such  health  care  policy groups  as the  National  Governors

Association,  the  National  Conference  of State  Legislatures  (NCSL),  the  Association  of

State  and  Territorial  Health  Officers,  the  Association  of Maternal  and  Child  Health

Programs,  the  National  Association  of County  Health  Officers,  the  U.S.  Conference  of

13
 Local  Health  Officials,  CityMatCH,  the  Health  Mothers/Healthy  Babies  Coalition,  an 
the  Washington  Business  Group  on Health. 
14  BIBLIOGRAPHY

American  Academy  of Pediatrics.  1991.  Repoti  of the Committee  of Infectious 
Dkeases,  22nd Edition  (Z%eRed Book).  Elk  Grove,  IL.: American  Academy  of 
Pediatrics. 
Association  of Maternal  and  Child  Health  Programs.  1992.  AMCHP  LJPDIIT-ES: 
NOVEMBER  1992.  Washington,  D.C. 
Association  of Maternal  and  Child  Health  Programs.  February  1991.  Meeting the 
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OBRA  89.  Washington,  D.C. 
Center  for the  Future  of Children.  1992.  Health  Care  Services  for Children  and 
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Maternal  and  Child  Health  Bureau.  1992 MCH Block  Grant Guidance,  Draft. 
Rockville,  Maryland:  PHS/HRSA/MCHB. 
National  Conference  of State  Legislatures.  1991.  Maternal  and Child Health  Care 
Legislation:  1991.  Denver,  CO. 
National  Institute  of Child  Health  and  Human  Development.  October  5, 1992.  Are 
We  Protecting  Our  Childrens  Future?  1992 Child Heal~h Day Information  Packet. 
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National  Vaccine  Program. 
Omnibus  Budget  Reconciliation  Act  of  1989 (P.L.  101-239).  December  19, 1989:103 
STAT.  2273 -2285Subtitle  C--Maternal  and  Child  Health  Block  Grant  Program, 
Section  6501 -6510.  United States  Code: Congressional and Administrative  News, 
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Publishing  Co. 
Orenstein,  W.A.,  W. Atkinson,  D. Mason,  and  R.H.  Bemier.  1990.  Barriers  to 
Vaccinating  Preschool  Children.  Journal of Health  Care for the Poor and 
Uruienerved  1 (No.  3, Winter)  :315-330. 
Southwest,  an Aetna  Plan.  1993.  Healthwzke Today Newsletter.  Irving, Texas: 
Southwest,  an Aetna  Plan. 
15
 U.S.  Department  of Health  and  Human  Services.  January  29, 1992.  The Fiscal Year 
1993 Budget.  Washington,  D.C. 
U.S.  Department  of Health  and  Human  Services/Office  of Inspector  General/Office  of 
Evaluations  and  Inspections.  l%e National  Vaccine Insurance Compensation  Program: 
A  Review  (OEI-02-91-01460).  Work  in progress. 
U.S.  Department  of Health  and  Human  Services/  Public  Health  Semite.  Healthy 
People  2000:National  Health  Promotion  and Dkease  Prevention  Objectives. 
Washington,  D. C.: Government  Printing  Office. 
U.S. Department  of Health  and  Human  Services/  Public  Health  Service.  May  11, 
1992.  HHS News.  Atlanta,  GA:  CDC  Press  Office. 
U.S.  Department  of Health  and  Human  Services/  Public  Health  Service.  August  31, 
1992.  HHS News.  Atlanta,  GA.  CDC  Press  Office. 
U.S.  Department  of Health  and  Human  Services/  Public  Health  Service/Centers  for 
Disease  Control  and  Prevention.  October  1992.  Guidelines for Assessing  Vaccination 
Levels  of the 2-year-old Population  in a Clinic Semng. Atlanta,  GA:  Division  of 
Immunizations. 
U.S.  Department  of Health  and  Human  Sewices/Public  Health  Service/Health 
Resources  and  Services  Administration.  January  1992.  HRSA  Profi/e.  Washington, 
D.C. 
U.S.  Department  of Health  and  Human  Services/Public  Health  Semite/Office  of 
Health  Communications/Communications  and  Service  Division.  1991.  The Healthy 
Difference I+ograrn Guide.  Washington,  D.C. 
U.S.  Department  of Health  and  Human  Services/Public  Health  Sewice/Office  of the 
Assistant  Secretary  for Health.  1990.  Secreta@s  Program Directions Regarding PHS 
Immunuation  Initiatives.  Washington,  D.C. 
U.S.  Department  of Health  and  Human  Services/Public  Health  Service/Office  of the 
Asistant  Secretary  for  Health.  April  6, 1992.  Quarter@ Summaty  Repons:  Z7ze 
Secreta&s  Program Directions Regarding PHS Immunization  Initiatives.  Washington, 
D.C. 
U.S.  General  Accounting  Office.  May  1992.  Federally Funded Heahh  Services: 
Infonnahon  on Seven programs  Serving Low-Income  Women and  Children. 
Washington,  D.C.:  U.S.  General  Accounting  Office  (GAO/HRD-92-73FS). 
U.S.  General  Accounting  Office.  June  1992.  Childhood  Immunizations:  Oppotlunihes 
to Improve  Immuntiahon  Rates  at Lower  Cost  (Testimony).  Gaithersburg,  MD: 
U.S.General  Accounting  Office  (GAO/T-HRD-92-36). 
16  APPENDICES 
Appendix  A  Preliminary  Immunization  Data 
Appendix  B  Full Text  of Agency  Comments  APPENDIX  A

PRELIMINARY  MMUNLZATION  DATA  As of September  1992* 
PERCENT  OF TWO-YEAR-OLDS  WITH 
COMPLEIE  IMMUNEATfONS 
=ATES  19X)  1991 
Alabama  72.4 
Alaska  57.5 
Arizona  46 
California  48.2 
Colorado  60.8 
Connecticut  64 
Delaware 
District of Columbia

Florida
 63.2 
Georgia
 68 
Hawaii

Idaho
 60 
Illinois

Indiana
 56 
Iowa
 51.7 
Kansas  51.3 
Kentucly  50.3 
Louisiana  56 
Maine  63.2 
Maryland  56.6 
Massachusetts 
Michigan  60.1 
Minnesota  61.4 
Mississippi  43 
A-1
 PERCENT  OF TwO-YEAR-OLDS  WITH 
COMPLIZIE IMMUNUATIONS 
STATES  1990  1991 
Missouri  43 
I  I 
Montana 
Nebraska

Nevada

New Hampshire
 65.8

New Jersey
 50.2

New Mexico

New York

NorthCarolina
 33.3

NorthDakota
 68

Ohio
 51.9

Oklahoma
 33

Oregon
 53

Pennsylvania
 65.6

RhodeIsland
 62

SouthCarolina
 52.2

SouthDakota
 55.8

Tennessee
 74.4

Texas
 50 
Utah
 36.5 
Vermont
 83.6 
Virginia
 68.8 
Washington
 51.2 
West Virginia

Wisconsin
 58.8 
Wyoming
 68.3 
Maternaaln dChilHde altBhu reauP,u bliHce altShe rviuD,e partmenotfH ealtahn
 dHuman

Service*(sA.ll 
 U.S. tenitories  are excluded porn  the chart). 
A-2  APPENDIX  B 
AGENCY  COMMENTS 
SERVICE 
PUBLIC  HEALTH 
B-1  I1993 
0(X
Frbm:  Assistant  Secreta~  for  Health 
. 
General  (OIG)  Ilraft  Report  The 
Subject:	 Of ff-ce  of  Inspector  Maternal  and Child Health  Bureau 
Role of the Federal  OE1-06-91-01180 
in Preschool  Immwizations~

Acting  Inspector  General,  OS 
TO: 
to the subject

Public  Health  Service  response
reports recommendations 
Attached  is  the 
We concur with the 
OIG draft report. we have taken or plan to

describe the actions 
and our cements

take to implement the .

~~.g,$

Attachment
 PUBLIC  HEALTH SERVICE  (PHS) COMMENTS ON THE OFFICE OF

lNSPECTOR  GENE- fOIG\ DRAFT REPORT  THE ROLE OF THE FEDEm

MATERNAL  AND CHILD HEALTH  BUREAU IN PRESCHOOL  IMMUN1~ATIONS~

OEI-06-91-01180

General  Comments 
Immunization  is  a  high  priority  of  the  Maternal  and  Child 
Health  Bureau  (MCHB).  This is underscored  by MCHBS  selection 
of an immunization  objective  as one of the key national

maternal  and child health  (MCH) objectives  for the year  2000.

increasing  immunization  rates is absolutely  essential  for the

delivery  of adequate  primary  care.  MCHB continues  to support

the development  of systems that assure that immunization  i.sa

critical  component  of comprehensive  primary  care.

OIG Recommendation

1.	 The PHS should ensure  that the MCHB  strengthen  its

guidance  and direction  to State MCH programs  to incr~ase

preschool  immunization  rates in addition  to other

comprehensive  care services.

PHS Comment

We concur with this recommendation  and with the four actions 
which  the OIG report  suggests  that MCHB  could take to fulfill 
it.  The proposed  revision  to the MCH Block Grant application 
and annual  report guidance,  currently  undergoing reviewt 
requires that States focus on  programming to achieve the 
Healthy People 2000 immunization goal.  In addition, the 
Annual Report Requirements for the MCH Block Grant Review

Criteria  currently  require that State applicants provide

immunization outcome information describing the proportion of

children who, at their second birthday, have been vaccinated

against measles, mumps, rubella, polio, diphtheria~ tetanus~

pertussis, Hib, and hepatitis B by racial and ethnic group.

The Health Resources and Services Administration (HRSA)

believes that the changes in the Block Grant review process

will fully address the concerns raised by OIG.

OIG Recommendation

2.	 The PHS should ensure that the MCHB and the Centers for 
Disease Control and Prevention (CDC) closely collaborate 
to assure a coordinated effort to improve.the immunization 
surveillance, reporting and delivery system.

PHS Comment

We concur.  By law, the MCHB must collect data from  each  State 
Title V program [Social Security Act, Title V] concerning  the 
immunization status of two year old children.  MCHB is  working  2

with  the  States  to  integrate  the  Title  V  reporting  requirements

into  a  single  common  reporting  system  that  will  satisfy

numerous  reporting  requirements  and  assure  that  children  and

families  actually  receive  comprehensive  health  services.  MCHB

also provides  technical  assistance  to States through grants  or

the MCHBS  Maternal  and Child Health  Information Resource

Center.

The  omnibus  Budget  Reconciliation  Act  of  1989  (OBRA  89)  Title  v

State  reporting  requirements  related  to  immunization  data

collection  and  reporting  activities  are  being  coordinated  with

CDCS  efforts  at  both  the  State  and  local  levels.  The  MCHB has

convened and chairs a Federal Interagency work group on MCH

data.  This group includes representatives from CDC, the

Administration for Children and Families (ACF), the Health Care

Financing Administration, and the Department of Education.  The

first two projects of this work group are to standardize

definitions and simplify reporting requirements.  .

In addition, MCHB and CDC work jointly to develop reporting

strategies to systematically assess immunization status in a

timely, recurring basis.  Together they have sponsored two

State MCH data meetings to strengthen coordination and problem

solving, and they support data collection efforts and reporting

requirements under development. by the Public Health Foundation.

MCHB  and CDC continue  to woxlctogether  to coordinate  efforts  to

meet  the OBRA 89 immunization  reporting  requirements  and the

Departments  Healthy  Pec@e  2000 objective  and goal related  to

immunization.

We agree with OIG that it is essential for State MCH programs

to be involved in the development and implementation  of CDCS

local immunization  action  plans  (IAP).  We are aw=e  of manY

directors  of State MCH programs  or programs  for children  with

special  health  care needs who have been involved  in the

development  and implementation  of the IAls Uqder their

jurisdiction.  MCHB will  assess whether  all States have 
appropriately  involved  their  Title V programs  in the 
development  and implementation  of IAPs  and  will  work with  CDC 
to assure  participation  if they have not. 
Finally, to improve surveillance and data collection efforts~

14CHBhas convened a panel of experts with representatives from

State and local governments, foundations, and universities to

improve MCH analysis for qualitative and quantitative problem

solving.  MCHB has worked with New York City, the Western

Governors Associationr the Robert Wood Johnson Foundation, and

the Pew Charitable Trust to develop an immunization tracking

system and/or smart card to assist local providers in

assuring that children receive proper age-appropriate

immunizations.
 3

OIG Recommendation

3.	 The PHS and the ACF should develop an acceptable 
arrangement  that assures  technical assistance  for 
immunizations  is  provided  to  the Head Start program  and 
its  grantees. 
PHS  Comment 
The  ACF  has  responsibility  for administering  the  Head  Start 
program and PHS involvement is at  the  request of ACF.  PHS is 
prepared to assist ACF by providing technical assistance and 
expertise in public health matters.  We believe that the five 
year interagency agreement between ACF and MCHB was an 
excellent demonstration of how two Federal programs~ working 
collaboratively, could provide the best services of each 
program to improve, promote and maintain the health of high-
risk infants, preschool children and their families.  ._ 
It is our understanding that the Head Start Bureau  (HSB) of ACF

had decided  to coordinate  its health technical  assistance

activities  through the same mechanism  they use to deliver

technical  assistance  for education,  social sexwices,  and

parents.  We respect  their prerogative  to discharge  their

responsibilities  in the way  they see fit.  However,  should HSB

decide  to re-negotiate  the interagency  agreement  with MCHB

(that expired  on September  30, 1992) to provide  the health

component  of the Head Start program  through a Federal,  State

and local network  for technical  assistance  and training,  MCHB

is willing  to work with  them to reach a mutually  satisfactoq

agreement.