Immunization in the new millennium: meeting the challenge to realize the promise.

This special issue of the American Journal of Preventive Medicine features work initiated by the Institute of Medicine’s (IOM) Committee on Immunization Finance Policies and Practices. The Committee was charged by the U.S. Senate Committee on Appropriations and the Centers for Disease Control and Prevention (CDC) to evaluate program performance and expenditures for immunization activities over the past decade. Specifically, the Committee was asked to review total expenditures for that period; review contributions and trends in State expenditures to determine whether new federal funding mechanisms such as the Vaccines for Children (VCF) program resulted in a reduction of effort at the state level; project future requirements for funding for immunizations from all sources, with particular attention to Section 317 grant funds; recommend a mechanism to distribute federal grant funds to states; suggest ways to target those funds on high-risk populations without compromising overall immunization coverage; and address the role of CDC in supporting state immunization activities for adults and achieve the nation’s goals for influenza and pneumococcal vaccines. Central to the Committee’s task has been an in-depth analysis of the Section 317 program. This federal grant program, first enacted in 1963, is administered by CDC’s National Immunization Program and is authorized to assist state and local governments in the prevention and control of communicable disease. The program accomplishes this goal through the direct purchase of vaccines and the support of administrative and service delivery activities, including surveillance of infectious disease, immunization coverage and vaccine safety, training of immunization providers, and education and outreach activities. To inform its deliberations, the 15-member Committee commissioned a survey of state immunization programs, eight case studies, and background papers on subjects such as the legislative history of federal immunization programs and the fiscal structure of federal programs supporting immunization and health care, and held a workshop in September 1999 addressing issues surrounding populations at high risk for underimmunization. Much of the empirical research and policy analysis conducted by IOM Committee members, staff, consultants, and the CDC’s National Immunization Program staff as part of the Committee’s work is presented here. In reviewing the funding history of this program and in analyzing expenditures for vaccine purchase and support for the public health infrastructure for immunization during the 1990s, the committee addressed the instability of federal support for infrastructure in particular.1,2 Our nation’s progress toward eradicating vaccinepreventable diseases provides an aperture into the workings of the American health care system and, more specifically, the priorities of both the federal and state governments. The reduction of the burden of infectious disease represents one of the nation’s greatest health achievements in the latter half of the 20th century. Despite advances in science, only one disease—smallpox—has succumbed to our public health efforts utilizing the technology of modern immunization practice. Although progress has been substantial in the reduction of vaccine-preventable disease over the last two decades, periodic incursions by microbes have resulted in several major outbreaks. Nationally, coverage rates for children are at an all-time high; however, coverage rates in certain regions of the country and large metropolitan areas remain low. In 1998, statewide coverage levels for 2-year-olds for the 4:3:1:3 series varied widely, from 71% to 90.4%.3 Furthermore, children below the poverty level are less likely to be fully immunized than children above it. Following the measles resurgence of 1989–1991, the National Vaccine Advisory Committee (NVAC) concluded that, despite advances in vaccine development, complacency combined with a fragmented delivery and financing system contributed to increased rates of disease morbidity and mortality. Missed opportunities, disjointed state and federal programs for children, and an inability to track and verify immunization coverage in both private practices and public clinics were cited as contributing factors in the measles outbreaks.4 No single factor of health care delivery, health financing, or the science of vaccine development has From the Texas Tech University Health Sciences Center, Lubbock, Texas Dr. Smith is Vice Chair of the Institute of Medicine Committee on Immunization Policies and Practices. Address correspondence and reprint requests to: David R. Smith, MD, President, Texas Tech University Health Sciences Center, 2b158 HSC Bldg, Lubbock, TX 79409. E-mail: adm1drs@ttuhsc.edu.