Vaccines for Children Program

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Vaccination rates for preschool-aged children from 1967-2012, with Vaccines for Children program era marked. Immunization rates for all pre-school aged children increased to at least 90% for most vaccines in the 1990s. It is difficult to discern if this increase was directly caused by the VFC program. (Abbreviations: DTP/DTaP = diphtheria, tetanus, pertussis or diphtheria, tetanus, acellular pertussis; MMR = measles, mumps, and rubella; Hib = Haemophilus influenzae type b; Hep B = hepatitis B; PCV = pneumococcal conjugate vaccine; RV = rotavirus vaccine; Hep A = hepatitis A.) Vaccine coverage rates among preschool-aged children (1967-2012).gif
Vaccination rates for preschool-aged children from 1967–2012, with Vaccines for Children program era marked. Immunization rates for all pre-school aged children increased to at least 90% for most vaccines in the 1990s. It is difficult to discern if this increase was directly caused by the VFC program.
(Abbreviations: DTP/DTaP = diphtheria, tetanus, pertussis or diphtheria, tetanus, acellular pertussis; MMR = measles, mumps, and rubella; Hib = Haemophilus influenzae type b; Hep B = hepatitis B; PCV = pneumococcal conjugate vaccine; RV = rotavirus vaccine; Hep A = hepatitis A.)

The Vaccines for Children Program (VFC) is a federally funded program in the United States providing no-cost vaccines to children who lack health insurance or who otherwise cannot afford the cost of the vaccination. The VFC program was created by the Omnibus Budget Reconciliation Act of 1993 and is required to be a new entitlement of each state's Medicaid plan under section 1928 of the Social Security Act. [1] The program was officially implemented in October 1994 and serves eligible children in all U.S. states, as well as the Commonwealth of Puerto Rico, the U.S. Virgin Islands, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. [2] [3]

Contents

History

From 1989 through 1991, a measles epidemic in the United States resulted in over 55,000 reported cases of measles, 11,000 measles-related hospitalization, and 123 deaths. [4] Upon investigation, Centers for Disease Control and Prevention (CDC) found that more than half of the children who had measles had not been immunized, despite seeing a health care provider. [5] In partial response to that epidemic, Congress passed the Omnibus Budget Reconciliation Act (OBRA) on August 10, 1993, creating the VFC Program; the VFC program officially became operational October 1, 1994. [6]

The Vaccines for Children program represented a major vaccine finance reform, working as a state-operated federal entitlement program that supplied both public and private providers with federally purchased vaccines. This integration of both the public and private sector benefitted all providers. Because private providers now had a role in the nation's immunization program, they, along with the public health sector, benefitted from the supply of vaccines at no cost, educational opportunities, and the ability to provide immunization services to patients without a need for referral. [7] As of 2019, there are over 44,000 doctors at 40,000 locations enrolled in the VFC program nationwide. [3]

Outcomes and impact

By eliminating or reducing cost as a barrier to vaccination, the VFC program encourages improved vaccination coverage among eligible children. [2] Increased vaccination protects not only vaccinated child themselves, but also indirectly protects those around them through herd immunity, which can slow or stop the spread of disease. Thus childhood vaccination, as opposed to vaccination later in life, is particularly effective as a means of controlling and preventing disease spread. [8]

The VFC program results in millions of immunizations each year. In 2010 alone 82 million VFC vaccine doses were administered to approximately 40 million children. [9] Due to the exponential impact of vaccination, it is difficult to separate the effect of the VFC from that of other state and federal immunization programs. For example, it is difficult (or perhaps impossible) to disentangle the effects of the VFC program and the increase in public school vaccination requirements that occurred during the 1990s and 2000s. [10] Thus, research primarily focuses the overall effect of increased childhood immunization that began in the mid-1990s, much (but not all) of which is owed to the VFC program.[ citation needed ]

The CDC estimates that among children born from 1994 to 2013 (that is, children born during the VFC-era), "routine childhood immunization... [will] prevent 322 million illnesses (averaging 4.1 illnesses per child) and 21 million hospitalizations (0.27 per child) over the course of their lifetimes and avert 732,000 premature deaths from vaccine-preventable illnesses". All told, vaccination among this birth cohort will prevent an estimated 8.9 million measles-related hospitalization and 507,000 diphtheria-related deaths. [11] These rates do not include prevented hospitalizations and deaths resulting from annual influenza immunizations, which the VFC also provides. Additionally, these estimates do not account for the rise in US population during this time period. Both of these factors have the potential to make the CDC's estimates artificially low.[ citation needed ]

The VFC program has also significantly helped close the vaccination rate gap between non-Hispanic whites and other racial groups. During the measles epidemic of 1989–1991, racial/ethnic minority children were 16 times more likely than non-Hispanic white children to contract measles. Due in part to the VFC program, there have been no racial/ethnic disparities in measles-mumps-rubella vaccination in the United States since 2005, and racial disparities for other vaccinations have declined or become absent entirely, depending upon the vaccination and the racial group studied. [4] Overall, while immunization disparities still exist for newer vaccines (i.e. HepA, rotovirus, and HPV), the VFC has effectively eliminated the immunization gap for older vaccines like MMR, polio, and HepB. [12]

Vaccination programs like the VFC are expensive, but they also result in significant cost savings through prevented hospitalization and doctor visits. Routine childhood vaccination among the 1994-2013 birth cohort is estimated to result in $107 billion in direct costs and $121 billion in social costs. In return, childhood vaccination results in the aversion of $402 billion in direct costs and $1.5 trillion in societal costs. This gives vaccination a net present value (net savings) of $295 billion and $1.38 trillion in direct and societal costs, respectively. [11]

Due to the VFC program, the Federal government of the United States currently purchases between 52 and 55 percent of childhood vaccines administered in the United States. Such large-scale purchases by the federal government are not without economic consequences; the VFC program is one factor contributing to the current deterioration of the U.S. vaccination market. Thirty years ago, dozens of manufacturers produced vaccines for the U.S. market, but today just five companies produce all of the vaccines for children and adults in the United States. [13] The opportunity for large government contracts has led pharmaceutical companies to engage in such aggressive price competition that the market for vaccinations has all but collapsed. This collapse has occurred despite the fact that the U.S. vaccine market has been expanding for decades and is expected to continue expanding. This poses significant problems in the area of vaccine research and development, as there is currently little incentive for innovation within the market. [14]

Program

The VFC program is funded through an approval by the Office of Management and Budget (OMB), and the funds are allocated to the Centers for Disease Control and Prevention (CDC). The CDC buys vaccines at a discount directly from manufacturers and distributes them to state health departments and certain local and territorial public health agencies. The agencies then redistribute the vaccines at no cost to those private physicians' offices and public health clinics that are registered as VFC program providers. [3] Though the National Center for Immunization and Respiratory Diseases (NCIRD) (previously known as NIP) at CDC is responsible for policy development, state health departments are responsible for management of the VFC program at the state and local level. Most states thus coordinate their state-level immunization programs with the VFC. The successful implementation of the VFC at the state-wide level thus requires the cooperation and coordination of several state and federal agencies, including: The Centers for Medicare and Medicaid Services; the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); the Children's Health Insurance Program (CHIP); and the Health Resources and Services Administration (HRSA), among others. In fact, many parents first learn about the VFC program through other federal or state programs that they may or their children already participate in, like WIC or CHIP. The participation and cooperation of Medicaid is particularly important, as the majority of VFC-eligible children are also eligible for Medicaid; state and local Medicaid agencies thus play a crucial role in informing potentially eligible patients about the VFC program, as well as recruiting private physicians to participate in the program. [2]

Patient eligibility

Children and adolescents are eligible if it is before their 19th birthday and if they meet one or more of the following criteria: [15]

Based upon these guidelines, the CDC estimates that approximately 50% of children under 19 years old are eligible for VFC benefits. [11]

* Underinsured means that a child that is covered by some type of health insurance, but the insurance either does not cover any vaccines, covers only certain vaccines, or does cover some vaccines, but has a cap on the annual cost for vaccines*. Underinsured children and adolescents may only receive vaccines at sites that are federally qualified health centers (FQHCs) or rural health clinics (RHCs). [16] Each state has an administrative fee set by the state that can never be exceeded, of about US$15. [17]

As of 2018, many children have benefited from the VFC program, which has saved nearly 936,000 from preventable diseases. Many families are benefiting from this program as it covers vaccines and helps with the costs of vaccines for low-income families. Records indicate that from 1994 to 2012 after immunizations began to rise, diseases such as polio and hepatitis B decreased drastically. [11]

Covered vaccines

The Advisory Committee on Immunization Practices (ACIP) makes recommendations to the VFC program as to what are the most appropriate selection of vaccines and related agents for control of vaccine-preventable diseases in the civilian population of the United States. [18] VFC resolutions passed by the ACIP form the basis for VFC program policies on vaccine availability and usage. These resolutions may not necessarily match the general usage recommendations of the ACIP, but rather represent the rules that providers must follow for administering each specific vaccine under the VFC program. [19]

The following vaccines are included in the VFC Program: [15]

* Vaccines initially targeted by the VFC program in 1994.

** Vaccines added to the VFC program from 1995 to 2013. [11]

Latest changes

The VFC program has implemented several regulations to address the changing needs of grantees:

In attempts to address fraud and abuse, grantees must now submit a copy of the newly written fraud and abuse policy, which includes identification of staff responsible for these issues, to the CDC no later than December 31, 2007. [20]

The VFC program is also requiring the update of user profiles. Rather than having grantees do this task, the goal is to improve accountability and ensure accurate information about the population of eligible children. [20]

A larger and more recent enhancement aiming to improve vaccine management at multiple levels (federal, state, local) is the initiation of the Vaccine Management Business Improvement Project (VMBIP). This project aims to simplify the ordering and distribution projects of vaccines, implement a more efficient supply system, and enable direct delivery of vaccines to providers. [20]

Related Research Articles

<span class="mw-page-title-main">Vaccination</span> Administration of a vaccine to protect against disease

Vaccination is the administration of a vaccine to help the immune system develop immunity from a disease. Vaccines contain a microorganism or virus in a weakened, live or killed state, or proteins or toxins from the organism. In stimulating the body's adaptive immunity, they help prevent sickness from an infectious disease. When a sufficiently large percentage of a population has been vaccinated, herd immunity results. Herd immunity protects those who may be immunocompromised and cannot get a vaccine because even a weakened version would harm them. The effectiveness of vaccination has been widely studied and verified. Vaccination is the most effective method of preventing infectious diseases; widespread immunity due to vaccination is largely responsible for the worldwide eradication of smallpox and the elimination of diseases such as polio and tetanus from much of the world. However, some diseases, such as measles outbreaks in America, have seen rising cases due to relatively low vaccination rates in the 2010s – attributed, in part, to vaccine hesitancy. According to the World Health Organization, vaccination prevents 3.5–5 million deaths per year.

<span class="mw-page-title-main">Measles</span> Viral disease affecting humans

Measles is a highly contagious, vaccine-preventable infectious disease caused by measles virus. Symptoms usually develop 10–12 days after exposure to an infected person and last 7–10 days. Initial symptoms typically include fever, often greater than 40 °C (104 °F), cough, runny nose, and inflamed eyes. Small white spots known as Koplik's spots may form inside the mouth two or three days after the start of symptoms. A red, flat rash which usually starts on the face and then spreads to the rest of the body typically begins three to five days after the start of symptoms. Common complications include diarrhea, middle ear infection (7%), and pneumonia (6%). These occur in part due to measles-induced immunosuppression. Less commonly seizures, blindness, or inflammation of the brain may occur. Other names include morbilli, rubeola, red measles, and English measles. Both rubella, also known as German measles, and roseola are different diseases caused by unrelated viruses.

<span class="mw-page-title-main">MMR vaccine</span> Any of several combined vaccines against measles, mumps, and rubella

The MMR vaccine is a vaccine against measles, mumps, and rubella, abbreviated as MMR. The first dose is generally given to children around 9 months to 15 months of age, with a second dose at 15 months to 6 years of age, with at least four weeks between the doses. After two doses, 97% of people are protected against measles, 88% against mumps, and at least 97% against rubella. The vaccine is also recommended for those who do not have evidence of immunity, those with well-controlled HIV/AIDS, and within 72 hours of exposure to measles among those who are incompletely immunized. It is given by injection.

<span class="mw-page-title-main">DPT vaccine</span> Class of combination vaccines

The DPT vaccine or DTP vaccine is a class of combination vaccines against three infectious diseases in humans: diphtheria, pertussis, and tetanus. The vaccine components include diphtheria and tetanus toxoids and either killed whole cells of the bacterium that causes pertussis or pertussis antigens. The term toxoid refers to vaccines which use an inactivated toxin produced by the pathogen which they are targeted against to generate an immune response. In this way, the toxoid vaccine generates an immune response which is targeted against the toxin which is produced by the pathogen and causes disease, rather than a vaccine which is targeted against the pathogen itself. The whole cells or antigens will be depicted as either "DTwP" or "DTaP", where the lower-case "w" indicates whole-cell inactivated pertussis and the lower-case "a" stands for "acellular". In comparison to alternative vaccine types, such as live attenuated vaccines, the DTP vaccine does not contain the pathogen itself, but rather uses inactivated toxoid to generate an immune response; therefore, there is not a risk of use in populations that are immune compromised since there is not any known risk of causing the disease itself. As a result, the DTP vaccine is considered a safe vaccine to use in anyone and it generates a much more targeted immune response specific for the pathogen of interest. However, booster doses are recommended every ten years to maintain immune protection against these pathogens.

<span class="mw-page-title-main">Vaccination schedule</span> Series of vaccinations

A vaccination schedule is a series of vaccinations, including the timing of all doses, which may be either recommended or compulsory, depending on the country of residence. A vaccine is an antigenic preparation used to produce active immunity to a disease, in order to prevent or reduce the effects of infection by any natural or "wild" pathogen. Vaccines go through multiple phases of trials to ensure safety and effectiveness.

The Advisory Committee on Immunization Practices (ACIP) is a committee within the United States Centers for Disease Control and Prevention (CDC) that provides advice and guidance on effective control of vaccine-preventable diseases in the U.S. civilian population. The ACIP develops written recommendations for routine administration of vaccines to the pediatric and adult populations, along with vaccination schedules regarding appropriate timing, dosage, and contraindications of vaccines. ACIP statements are official federal recommendations for the use of vaccines and immune globulins in the U.S., and are published by the CDC.

The MMRV vaccine combines the attenuated virus MMR vaccine with the addition of the chickenpox vaccine or varicella vaccine. The MMRV vaccine is typically given to children between one and two years of age.

The National Center for Immunization and Respiratory Diseases (NCIRD), formerly known as the National Immunization Program until April 2006, is charged with responsibility for the planning, coordination, and conduct of immunization activities in the United States. NCIRD is a part of the Centers for Disease Control and Prevention, located in Atlanta, Georgia, and housed in the CDC's Coordinating Center for Infectious Diseases (CCID). The National Center for Immunization provides consultation, training, statistical, promotional, educational, epidemiological, and technical services to assist state and local health departments across the US in planning, developing, contracting and implementing immunization programs.

<span class="mw-page-title-main">Zoster vaccine</span> Vaccine to prevent shingles

A zoster vaccine is a vaccine that reduces the incidence of herpes zoster (shingles), a disease caused by reactivation of the varicella zoster virus, which is also responsible for chickenpox. Shingles provokes a painful rash with blisters, and can be followed by chronic pain, as well as other complications. Older people are more often affected, as are people with weakened immune systems (immunosuppression). Both shingles and postherpetic neuralgia can be prevented by vaccination.

<span class="mw-page-title-main">Varicella vaccine</span> Vaccine to prevent chickenpox

Varicella vaccine, also known as chickenpox vaccine, is a vaccine that protects against chickenpox. One dose of vaccine prevents 95% of moderate disease and 100% of severe disease. Two doses of vaccine are more effective than one. If given to those who are not immune within five days of exposure to chickenpox it prevents most cases of disease. Vaccinating a large portion of the population also protects those who are not vaccinated. It is given by injection just under the skin. Another vaccine, known as zoster vaccine, is used to prevent diseases caused by the same virus – the varicella zoster virus.

A vaccination policy is a health policy adopted in order to prevent the spread of infectious disease. These policies are generally put into place by State or local governments, but may also be set by private facilities, such as workplaces or schools. Many policies have been developed and implemented since vaccines were first made widely available.

<span class="mw-page-title-main">Health in the United States</span> Overall health of the population of the United States

Health may refer to "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity.", according to the World Health Organization (WHO). 78.7 was the average life expectancy for individuals at birth in 2017. The highest cause of death for United States citizens is heart disease. Infectious diseases such as sexually transmitted diseases impact the health of approximately 19 million yearly. The two most commonly reported infectious diseases include chlamydia and gonorrhea. The United States is currently challenged by the COVID-19 pandemic, and is 19th in the world in COVID-19 vaccination rates. All 50 states in the U.S. require immunizations for children in order to enroll in public school, but various exemptions are available by state. Immunizations are often compulsory for military enlistment in the United States.

Vaccinate Your Family (VYF), formerly known as Every Child By Two (ECBT), is a non-profit organization, based in the United States, which advocates for vaccinations. Founded in 1991, its stated goals are to "raise awareness of the critical need for timely immunizations and to foster a systematic way to immunize all of America's children by age two." ECBT was founded by former First Lady of the United States Rosalynn Carter and former First Lady of Arkansas Betty Bumpers. ECBT was renamed to Vaccinate Your Family in 2018.

NmVac4-A/C/Y/W-135 is the commercial name of the polysaccharide vaccine against the bacterium that causes meningococcal meningitis. The product, by JN-International Medical Corporation, is designed and formulated to be used in developing countries for protecting populations during meningitis disease epidemics.

<span class="mw-page-title-main">Measles vaccine</span> Vaccine used to prevent measles

Measles vaccine protects against becoming infected with measles. Nearly all of those who do not develop immunity after a single dose develop it after a second dose. When rate of vaccination within a population is greater than 92%, outbreaks of measles typically no longer occur; however, they may occur again if the rate of vaccination decrease. The vaccine's effectiveness lasts many years. It is unclear if it becomes less effective over time. The vaccine may also protect against measles if given within a couple of days after exposure to measles.

<span class="mw-page-title-main">Rubella vaccine</span> Vaccine used to prevent rubella

Rubella vaccine is a vaccine used to prevent rubella. Effectiveness begins about two weeks after a single dose and around 95% of people become immune. Countries with high rates of immunization no longer see cases of rubella or congenital rubella syndrome. When there is a low level of childhood immunization in a population it is possible for rates of congenital rubella to increase as more women make it to child-bearing age without either vaccination or exposure to the disease. Therefore, it is important for more than 80% of people to be vaccinated. By introducing rubella containing vaccines, rubella has been eradicated in 81 nations, as of mid-2020.

A Vaccine Information Statement (VIS) is a document designed by the Centers for Disease Control and Prevention (CDC) to provide information to a patient receiving a vaccine in the United States. The National Childhood Vaccine Injury Act requires that medical professionals provide a VIS to patients before receiving certain vaccinations. The VIS includes information about the vaccine's benefits and risks, a description of the vaccine, indications and contraindications, instructions for patients experiencing an adverse reaction, and additional resources.

<span class="mw-page-title-main">Tetanus vaccine</span> Vaccines used to prevent tetanus

Tetanus vaccine, also known as tetanus toxoid (TT), is a toxoid vaccine used to prevent tetanus. During childhood, five doses are recommended, with a sixth given during adolescence.

<span class="mw-page-title-main">Measles resurgence in the United States</span> Sharp increase in measles cases between 2010 and 2019

Measles was declared eliminated from the United States in 2000 by the World Health Organization due to the success of vaccination efforts. However, it continues to be reintroduced by international travelers, and in recent years, anti-vaccination sentiment has allowed for the reemergence of measles outbreaks.

<span class="mw-page-title-main">Vaccination policy of the United States</span> Overview of the vaccination policy in the United States of America

Vaccination policy of the United States is the subset of U.S. federal health policy that deals with immunization against infectious disease. It is decided at various levels of the government, including the individual states. This policy has been developed over the approximately two centuries since the invention of vaccination with the purpose of eradicating disease from the U.S. population, or creating a herd immunity. Policies intended to encourage vaccination impact numerous areas of law, including regulation of vaccine safety, funding of vaccination programs, vaccine mandates, adverse event reporting requirements, and compensation for injuries asserted to be associated with vaccination.

References

  1. ↑ United States Congress. "§ 1928 Program for Distribution of Pediatric Vaccines". Social Security Act . Retrieved March 10, 2019– via U.S. Social Security Administration.
  2. 1 2 3 "VFC Childhood Vaccine Supply Policy". Vaccines for Children Program (VFC). Centers for Disease Control and Prevention. February 18, 2016. Retrieved March 5, 2019.
  3. 1 2 3 "VFC Home". Vaccines for Children Program (VFC). Centers for Disease Control and Prevention. February 18, 2016. Retrieved March 5, 2019.
  4. 1 2 Walker, Allison T.; Smith, Philip J.; Kolasa, Maureen (April 18, 2014). "Reduction of Racial/Ethnic Disparities in Vaccination Coverage, 1995–2011". Morbidity and Mortality Weekly Report (MMWR) Supplements. Centers for Disease Control and Prevention. 63 (1): 7–12. PMID   24743661 . Retrieved March 10, 2019.
  5. ↑ Dales, LG; Kizer, KW; Rutherford, GW; Pertowski, CA; Waterman, SH; Woodford, G (October 1993). "Measles epidemic from failure to immunize". Western Journal of Medicine . 159 (4): 455–64. PMC   1022280 . PMID   8273330.
  6. ↑ Hinman, Alan R.; Orenstein, Walter A.; Schuchat, Anne (October 7, 2011). "Vaccine-Preventable Diseases, Immunizations, and MMWR". Morbidity and Mortality Weekly Report (MMWR) Supplements. Centers for Disease Control and Prevention. 60 (4). OCLC   756044361 . Retrieved March 11, 2019.
  7. ↑ Santoli, Jeanne M.; Rodewald, Lance E.; Maes, Edmond F.; Battaglia, Michael P.; Coronado, Victor G. (August 1999). "Vaccines for Children Program, United States, 1997" (PDF). Pediatrics. 104 (2): 9. doi: 10.1542/peds.104.2.e15 . PMID   10429133.
  8. ↑ Ventola, C. Lee (July 2016). "Immunization in the United States: Recommendations, Barriers, and Measures to Improve Compliance". Pharmacy and Therapeutics. 41 (7): 426–436. ISSN   1052-1372. PMC   4927017 . PMID   27408519.
  9. ↑ Levinson, Daniel (June 2012), Vaccines for Children Program: Vulnerabilities in Vaccine Management (PDF), Department of Health and Human Services, Office of Inspector General, retrieved March 11, 2019
  10. ↑ Carpenter, Christopher; Lawler, Emily (January 2017), Working Paper 23107: Direct and Spillover Effects of Middle School Vaccination Requirements (PDF), Cambridge, Massachusetts: The National Bureau of Economic Research, retrieved March 10, 2019
  11. 1 2 3 4 5 Whitney, Cynthia G.; Zhou, Fangjun; Singleton, James; Schuchat, Anne (April 25, 2014). "Benefits from Immunization During the Vaccines for Children Program Era — United States, 1994–2013" (PDF). Morbidity and Mortality Weekly Report (MMWR). Centers for Disease Control and Prevention. 63 (16): 352–355. Retrieved March 10, 2019.
  12. ↑ Black, Carla L.; Yankey, David; Kolasa, Maureen (September 13, 2013). "National, State, and Local Area Vaccination Coverage Among Children Aged 19–35 Months — United States, 2012". Morbidity and Mortality Weekly Report (MMWR). Centers for Disease Control and Prevention. 62 (36): 733–740. Retrieved March 11, 2019.
  13. ↑ Institute of Medicine (US) Committee on the Evaluation of Vaccine Purchase Financing in the United States (2003). "Executive Summary". Financing Vaccines in the 21st Century: Assuring Access and Availability. Washington, DC: National Academies Press.
  14. ↑ DPI Research, Pediatric Vaccines Market: United States Industry Analysis, Trends, Opportunity, Market Size and Segment Forecasts, 2018 - 2025, Research and Markets, retrieved March 11, 2019
  15. 1 2 "VFC Detailed Questions and Answers for Parents". Vaccines for Children Program (VFC). Centers for Disease Control and Prevention. December 17, 2014. Retrieved March 12, 2019.
  16. ↑ Lindley, Megan C.; Shen, Angela K.; Orenstein, Walter A.; Rodewald, Lance E.; Birkhead, Guthrie S. (2009). "Financing the Delivery of Vaccines to Children and Adolescents: Challenges to the Current System" (PDF). Pediatrics. 124: S548-57. doi: 10.1542/peds.2009-1542O . PMID   19948587 – via AAP News & Journals.
  17. ↑ Cole, Megan (June 28, 2014). "The Vaccines for Children Program (VFC)". National Center for Health Research. Retrieved February 13, 2019.
  18. ↑ "ACIP General Committee Information | Immunization Practices | CDC". www.cdc.gov. January 8, 2019. Retrieved March 12, 2019.
  19. ↑ "ACIP Resolutions for Vaccines for Children Program". Vaccines for Children Program (VFC). Centers for Disease Control and Prevention. July 10, 2019. Retrieved April 6, 2020.
  20. 1 2 3 Ching, Pamela L.Y.H. (November–December 2007). "Evaluating Accountability in the Vaccines for Children Program: Protecting a Federal Investment". Public Health Reports . 122 (6): 718–24. doi:10.1177/003335490712200603. PMC   1997239 . PMID   18051664.
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