TlDepartment of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

E ROLE OF THE FEDERAL MATERNA . 

AND CHILD HEALTH BUREAU IN 

PRESCHOOL IMMUNIZATIONS 
OFFICE OF INSPE~OR GENERAL 

The mission oftheOffice ofInspector General(OIG),asmandatedby Public Law 95-452,
 as


amended,istoprotect theintegrity oftheDepartment ofHealthandHuman Services’
 (HHS)


programs aswellasthehealth andwelfare ofbeneficiaries served bythose programs.
 Thisstatutory 

mission iscarried outthrougha nationwide networkof audits, investigations, and inspections 

conducted by	threeOIG operating components:theOffice of AuditSefices, theOfficeof


Investigations, andtheOffice ofEvaluation adInspections. The OIG also informs
 theSecretary


ofHHS ofprogram, andmanagement problems, andrecommends courses tocorrect
 them.


OFFICE OF AUDIT SERVICES 

The OIGS Office of AuditServices (OAS) provides allauditing services forHHS, either
by


conducting audits withits own audit resources orbyoverseeing audit workdonebyothers.
 Audits


examine theperformance ofHHS programs and/or its grantees andcontractors incarrying
 outtheir


respective responsibilities andareintended toprotide independent assessments
 ofHHS programs


andoperations inordertoreduce waste, abuse, andmismanagement
 andtopromoteeconomyand


efficiency throughout
 theDepartment.


OFFICE OF INVESTIGATIONS 

The OIGS Office ofInvestigations (01)conducts cfiminal, ci~l, andadministrative instigations
 of


allegations of wrongdoing inHHS programs ortoHHS beneficiaries andofunjust enrichment
 by 

providers. The investigative efforts of01 leadtocriminal convictions, administrative sanctions, or


civil moneypenalties. The01 alsoversees State Medicaid fraud control units whichinvestigate
 and


prosecute fraud andpatient abuseintheMedicaid
program.


OFFICE OF EVALUATION AND INSPECTIONS 

TheOIGS Ofllce ofEvaluation andInspections (OEI)~nductsshort-term management
andprogram


evaluations (called inspections) that focus oniSSUeS of ~n~~ to the Department,heCongress,
 and 

thepublic. Thefindings andrecommendations contained inthese inspection reportsgenerate rapid, 

accurate, and up-to-date information ontheefficiency, vulnerability, andeffectiveness ofdepartmental


programs. Thisreport was prepared intheDallas regional office underthedirection
 ofRalph


Tunnell, Regional Inspector General andCh=terB.Slaughter, DeputyRegional Inspector
 General.


Project
 staffi


REGION HEADQUARTERS 

Carolyn R.Neuwirth, Project
 Leader MarutaZitans, Program Specialist 

Michelle Adams, Program Analyst Ann O’Connor, 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) 

Bureau’s 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 Bureau’s 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 President’s new initiatives and reflects the MCH Bureau’s 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 President’s initiatives. 

FINDINGS 

l’he 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 ImpRECOMMENDATIONS 

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 solicited and received cormnents fromPHS on ourdraft
report.PHS concurred 

w“thallourrecommendations and isintheprocess ofimplementingthem.


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) 

Bureau’s 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 vaccinepreventable 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 ‘T’he 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 nation’s 

health care system to deliver primary and preventive health care sexvices. 

Immunizations, besides being a responsible preventive health measure, are also a costeffective 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 nation’s 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 Nation’s 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 (OBRA89) have specified national maternal and child health status goals and objectives that 

should be attained by the States through reference to the Department’s “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~am’s (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 children’s 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 President’s new initiative and reflects the MCH 

Bureau’s 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 President’s 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 AMCHP’S survey of 

State Title V program activities, which include immunization-related activitiesll and 

2) CityMatCH’s 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 Bureau’s 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 committeetodevelopan immunization plan,aswellasaccompanying
CDC

regional staff duringsite visits toimmunization grantees intwo oftheregions;
 and


workingwithStates todeveloptheir CI.lCIrnrnunization ActionPlans, inaddition
 to


workingon otherCDC immunization
plansinanotherregion.


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(H’ION 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. PHF’s Project CAN-DO


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


include a self-assessment of each State’s 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 packet’s 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 President’s initiatives. The MCH Bureau’s 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 

Bureau’s full contribution to preschool immunization efforts and to the President’s 

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 

Bureau’s 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 President’s initiative continues to support rebuilding the 

infrastructure. CDC’S 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 State’s 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 ACF’S 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 PHS’S 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 state’s 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 ageappropriate 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 

Challenge: A Report on the First State I?rogramApplications for Title V as Amended by 

OBRA ’89. Washington, D.C. 

Center for the Future of Children. 1992. “Health Care Services for Children and 

Adolescents.” 7he Future of ChiZdren 2 (Number 2, Winter) :58-77. 

Interagency Committee on Immunizations. May 1992. Achon Plan to Improve Access 

to Immunization Services. Washington, D.C., National Vaccine Program. 

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 Children’s Future?” 1992 Child Heal~h Day Information Packet. 

National Vaccine Advisory Committee. January 8, 1991. me Measles Epidemic: 

l%oblerns, Bam”ers, and Recommendations [?%e Wtite Pauer~. Washington, D.C.: 

National Vaccine Program. 

Omnibus Budget Reconciliation Act of 1989 (P.L. 101-239). December 19, 1989:103 

STAT. 2273 -2285’’Subtitle C--Maternal and Child Health Block Grant Program, 

Section 6501 -6510.” United States Code: Congressional and Administrative News, 

Volume 3: Legislative Hirto~ for the 10lst Congress--First Session. St. Paul, MN: West 

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 Sem”ng. 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 

Alabama 

Alaska 

Arizona 

California 

Colorado 

Connecticut 

Delaware 

19X) 1991 

72.4 

57.5 

46 

48.2 

60.8 

64 

District of Columbia


Florida


Georgia


Hawaii


Idaho


Illinois


Indiana


Iowa


63.2 

68 

60 

56 

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 

Montana I I 

Nebraska


Nevada


New Hampshire


New Jersey


New Mexico


New York


NorthCarolina


NorthDakota


Ohio


Oklahoma


Oregon


Pennsylvania


RhodeIsland


SouthCarolina


SouthDakota


Tennessee


Texas


Utah


Vermont


Virginia


Washington


West Virginia


Wisconsin


Wyoming


65.8


50.2


33.3


68


51.9


33


53


65.6


62


52.2


55.8


74.4


50 

36.5 

83.6 

68.8 

51.2 

58.8 

68.3 

Maternal andChild Health Bureau, Public Health Serviu, Department ofHealth
andHuman


Services.
 *(All U.S. tenitories are excluded porn the chart). 

A-2 
APPENDIX B 

AGENCY COMMENTS 

PUBLIC HEALTH SERVICE 

B-1 
0(X”I1993 

Frbm: Assistant Secreta~ for Health 

. General (OIG) Ilraft Report “The 

Sub ject:	 Of ff-ce of Inspector Maternal and Child Health Bureau 

Role of the Federal OE1-06-91-01180 

in Preschool Immwizations~”


TO: Acting Inspector General, OS 

to the subject


Public Health Service response Attached is the We concur with the report’s recommendations 

OIG draft report.describe the actions we have taken or plan to


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 MCHB’S 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 MCHB’S 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


CDC’S 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 woxlc together to coordinate efforts to


meet the OBRA 89 immunization reporting requirements and the


Department’s 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 CDC’S


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 highrisk 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.


—