Mr. Chairman and Members of the Committee:

It is a pleasure to be here to share with you the preliminary results of our ongoing work on the Vaccine For Children (VFC) program. As you requested, I will present information on barriers to immunization, including our assessment of available evidence regarding the role of vaccine cost as a barrier for parents in immunizing their children.

First, however, I would like to underscore the importance of vaccines and the critical role that they play in protecting children from potentially serious diseases. Vaccines are the most cost-effective health intervention known.

Section 13631 of the Omnibus Budget Reconciliation Act of 1993 created VFC as an entitlement program to provide free vaccine to children 18 and younger who are eligible for Medicaid, Native American or Alaskan natives, uninsured, or underinsured (that is, whose insurance does not cover childhood vaccinations). The administration had stipulated that an increase in the cost of vaccine was a major factor in low rates of vaccination and proposed VFC to purchase and distribute vaccine supplies "to make sure that children do not become sick or die from vaccine preventable diseases."1 By providing free vaccines, VFC was intended to remove vaccine cost as a barrier to childhood immunization. VFC is a part of the Childhood Immunization Initiative (CII), the goal of which is to raise immunization rates for 2-year-old children to 90 percent for most antigens. By law, VFC is to provide the states with vaccines. The schedule established by the Public Health Service's Advisory Committee on Immunization Practices includes vaccines for measles, mumps, rubella, diphtheria, polio, tetanus, pertussis, hepatitis B, and hemophilus influenza. It is expected that the recently approved hepatitis A and varicella (chicken pox) vaccines will be added.

To assess barriers to immunization and the particular significance of vaccine cost as a barrier, we talked with CDC officials and reviewed pertinent literature and agency documents, including various types of information CDC cited to address vaccine cost as a cause of delayed immunization. In addition, we reviewed four major studies sponsored by CDC in the wake of recent measles epidemics to "diagnose" and identify reasons for low immunization rates among high-risk racial and ethnic minority inner-city preschoolers in Baltimore, Los Angeles, Philadelphia, and Rochester (New York). We reviewed CDC's four studies to assess the factors associated with underimmunization. Further, we convened an expert panel of the principal investigators of

1Centers for Disease Control and Prevention, National Immunization Program, The Childhood Immunization Initiative (Atlanta: April 1994), p. 1.

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these studies to help determine the extent to which the cost of vaccine for parents affects their children's vaccination status.

In our review of the available data and our discussions with the expert panel, we did not find sufficient evidence to conclude that vaccine cost has been a major barrier to children's immunization. The literature does identify many barriers, including parents' lack of awareness of their children's vaccination schedule, inadequate resources (for example, insufficient clinic staff, insufficient or inconvenient clinic hours, and inaccessible clinic locations), clinic policies that deter vaccination by requiring appointments or refusing to see walk-in patients, and various factors that cause providers to miss opportunities to immunize children at regular visits. We found that although a variety of socioeconomic and demographic variables are associated with undervaccination among inner-city children, these relationships appear to function not through cost but, rather, through other factors associated with poverty, such as family size and maternal education.

The findings from CDC's diagnostic studies indicate that most under immunized children have access to free vaccine through Medicaid or public health clinics (that is, through private or public providers) and that they had visited their providers an average of six to eight times during a given year. During these visits, these children could have received their scheduled immunizations, but providers failed to vaccinate them. These occasions are commonly known as "missed opportunities." Specifically, a missed opportunity is defined as a health care visit during which a child eligible for vaccination on the day of the visit and with no valid contraindication for vaccination fails to receive the needed vaccine.

CDC's studies identified several factors that are associated with missed opportunities. These primarily include provider and clinic-related factors and policies, such as failure to use simultaneous vaccinations or accelerated immunization schedules for children who are behind schedule, lack of access to records of a child's immunization status, and lack of organizational support. The missed opportunities observed in the diagnostic studies occurred during both sick- and well-child care visits. In fact, incorrect beliefs regarding contraindications for immunization are a particularly important contributor to missed opportunities. For example, CDC's diagnostic study in Baltimore reported that missed opportunities occurred at approximately 25 to 30 percent of preventive visits but at more than 75 percent of sick-child visits and that a health care provider was more likely

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