Celebrating 30 Years of Vaccines for Children (VFC)

Reducing Barriers to Vaccines

The Vaccines for Children (VFC) program impacts public health by ensuring young families and children have access to life-saving vaccines. The program provides free vaccines to eligible children through a network of health care providers, schools, and community centers.

Since its beginning in 1994, the VFC program has provided more than 71.5 billion doses of pediatric vaccines to more than 37,000 vaccine providers. Through these efforts, the program has reduced disparities, increased immunization rates, saved countless lives, and helped prevent the spread of infectious diseases.

A measles outbreak from 1989 to 1991 exposed vaccine inequities. The cost of the vaccine was a primary reason for children going unvaccinated even in families with a regular health care provider.

The outbreak was a catalyst for change, prompting widespread government action. In 1994, the VFC program was created to cover the cost of vaccines for children whose caregivers may be unable to afford them. The program removes the cost of vaccines as a barrier to keeping children on schedule with their recommended vaccinations.

This exhibition showcases the impact of the VFC program over its 30-year history and its evolution into one of the nation’s most important contributors to health equity.

A Nation in Crisis: The 1989-1991 Measles Epidemic

From 1989 to 1991, the U.S. experienced a resurgence of measles that resulted in about 55,000 cases, 11,000 hospitalizations, and 123 deaths. At the time, vaccines to prevent measles and other deadly childhood diseases had existed for decades. But children were not being vaccinated because their families did not have access to affordable vaccines. This inequity put the health of all children throughout the United States at risk. Between 1989 and 1991,

The cities and regions affected by the outbreak were geographically widespread but shared something in common. They were low-income communities where families lacked access to affordable vaccines for children and young adults. Children were going unvaccinated even in families with a regular health care provider.

In 1993, President Bill Clinton submitted to Congress the Comprehensive Childhood Immunization Initiative (CII) Act. The legislation set the expectation of vaccinating all children in the U.S. against nine preventable infectious diseases by their second birthday. The VFC program was authorized by the Omnibus Budget Reconciliation Act of 1993 and created to meet the goals of the CII. It was structured as a required entitlement program (a right granted by law) within each state’s Medicaid plan.

The VFC program became operational on October 1, 1994.

The number of measles cases was especially striking in California. The state saw an incidence rate of 2.6 cases per 100,000 persons in 1988 quadruple to 10.4 cases per 100,000 in 1989. The rate skyrocketed to 42.3 per 100,000 in 1990.

Researchers who examined the demographics of the outbreaks quickly recognized that California’s surge in cases was concentrated in low-income communities with high numbers of Hispanic residents, particularly in Los Angeles and the San Joaquin Valley.

CDC employees were present at the CII launch. CDC and the Ad Council took the opportunity to showcase new communication campaign materials. Note the poster in the background.

CDC communications materials in partnership with Ad Council

CDC launched a suite of new communications materials created in partnership with the Ad Council. The materials included posters, billboard ads, and public service announcements for television and radio. They encouraged caregivers to vaccinate their children when the CII was signed into law.

President Bill Clinton (seated) and Vice President Al Gore sign the CII Act in 1993.
Courtesy of the William J. Clinton Presidential Library and Museum

Creating a Strong Foundation for Vaccine Advocacy

Years before the Childhood Immunization Initiative (CII), advocates pushed for greater access to vaccines. In the 1970s, Betty Bumpers and Rosalynn Carter joined forces to increase vaccination rates in their states of Arkansas and Georgia, respectively. During the presidency of Jimmy Carter, the women pushed for greater support for vaccine distribution and access at the federal level and state laws to have every child entering kindergarten vaccinated.

In 1991, Bumpers and Carter founded Every Child by Two, now called Vaccinate Your Family (VYF). Bumpers and Carter were the catalysts behind the VFC Program. They also supported efforts to ensure children and pregnant people with Women Infants and Children (WIC) benefits are screened for immunizations.

VYF founders Rosalynn Carter (left) and Betty Bumpers (right) pictured alongside First Lady of Arkansas Hillary Clinton (center) at the “Arkansas Coalition Kickoff Event", 1991

Immunization Action News

Immunization advocates around the country saw the signing of the CII as a huge step forward. The CII set the goal of having 90% of children in the United States receive all their childhood immunizations by their second birthday. In 1996, the United States exceeded this goal with more than 90% of children receiving critical doses of childhood vaccines.

The original Vaccines for Children (VFC) logo from the 1994 launch.

Vaccines on the Move!

Health care providers are critical to extending the reach of the VFC program. They make it possible for VFC-eligible children to receive vaccines during routine appointments at their regular office, increasing the number of children vaccinated. Ensuring all VFC program vaccine providers have the knowledge and vaccines needed to participate in the program is critical to its success.

In 1994, critics doubted the General Services Administration’s ability to safely store and distribute vaccines. CDC developed solutions to ensure that vaccines went where they were needed most and that vaccine providers understood the new program. The agency worked with vaccine manufacturers to create a complex but effective system to distribute millions of doses of vaccines each year.

VFC program successes were undeniable. Every year, more children were up to date on their routine vaccinations. Their health care providers gave credit to VFC.

As the program has grown, CDC and its partners have found new ways to ensure that millions of doses of vaccine are distributed efficiently and that vaccine providers can navigate the system. In 2023, the VFC program distributed approximately 74 million doses of vaccines through this system.

Today, the VFC program works with health care providers to ensure they follow vaccine management practices (e.g., ordering, inventory maintenance, and storage and handling). These practices minimize vaccine loss and the risk of administering compromised vaccines.

VFC Operations Guide

The VFC Operations Guide was distributed at the start of the program in 1994. It provides information about the program and step-by-step instructions on how to order and properly store vaccines.

Called “The Binder” by CDC employees working on the VFC Program, this early operations guide was a crucial communication tool for the newly operational program.

Centralized Vaccine Distribution graphic

Each year, millions of doses of vaccines are ordered through the VFC program. In 2010, CDC launched a new software platform to track the entire VFC program vaccine supply chain. VTrckS (Vaccine Tracking System) keeps records of state immunization program vaccine planning, vaccine purchasing and inventory, and provider vaccine orders. This infographic shows how most vaccines purchased through the VFC program reach providers.

Vaccine providers enrolled in the VFC program must keep separate inventories of privately acquired vaccines and vaccines purchased through the VFC program.

The California Vaccines for Children Program in the California Department of Public Health created easy-to-use blank inventory sheets and stickers to help providers distinguish between the two stocks. The stickers are placed on the outside of vaccine boxes so that providers can easily see which vaccines were purchased with VFC funds.

Courtesy of the California Vaccines for Children Program.

Proper vaccine storage and handling are important factors in preventing and eradicating vaccine-preventable diseases. Each year, storage and handling errors result in revaccination of many patients and significant financial loss due to wasted vaccines.

Failure to store and handle vaccines properly can reduce vaccine potency. Reduced potency can result in inadequate immune responses in patients and poor protection against disease. Revaccination can cause patients to lose confidence in vaccines and providers.

Storage, care, and administration of vaccines can be a complex process. The VFC program requires providers to follow protocols that ensure vaccines are distributed safely to patients.

The California Vaccines for Children Program created a series of posters to help VFC vaccine providers navigate necessary protocols.

Courtesy of the California Vaccines for Children Program

A Model During the COVID-19 Pandemic

The COVID-19 pandemic presented unprecedented challenges for the United States public health infrastructure. Operation Warp Speed (OWS), a federal effort to speed up COVID-19 vaccine development and distribution, set an ambitious goal of distributing 300 million doses of COVID-19 vaccine by January 2021.

CDC and federal partners needed a distribution plan before a COVID-19 vaccine was developed and manufactured. Their plan addressed the complex challenge of equitably distributing the vaccines to more than thousands of doctors’ offices, pharmacies, and mass vaccination sites nationwide.

The VFC Program’s success in distributing vaccines directly to providers was instrumental in reaching this goal. The program served as a model for shipping COVID-19 vaccines from centralized distribution depots to providers.

On Dec. 14, 2020, COVID-19 vaccines made by Pfizer were packed and shipped to more than 600 locations. OWS leveraged vaccine ordering and distribution mechanisms used by the VFC program for routine distribution.

Terrence Wong, associate chief of pharmacy operations for Rocky Mountain Regional VA Medical Center, opens a box containing a shipment of the Pfizer-BioNTech COVID-19 vaccine on December 15, 2020, in Aurora, Colorado.
Photograph by Michael Ciaglo, Courtesy of Getty Images

The Eastern Colorado VA Health Care System was one of 37 VA centers to receive the vaccine because of their ability to store the vaccine at extremely cold temperatures and vaccinate many people.

During the first months of the COVID-19 pandemic, significant declines in VFC vaccine orders were noted in comparison to the same period in 2019. Corresponding declines were noted in measles vaccination coverage among publicly and privately insured children receiving care through eight large health care organizations in the United States.

Well-child visit attendance – a doctor’s visit when many children receive their vaccines – also decreased, resulting in fewer children being up to date with their recommended vaccines compared to pre-pandemic years. Taken together, these findings suggest that parental concerns about potentially exposing their children to COVID-19 during well-child visits might have been one of the reasons contributing to the trends observed.

In 2021, CDC issued a call to action to health care providers, health care systems, parents, and state and local governments to promote catch-up vaccination as children returned to in-person learning and care.

One of the most challenging aspects of distributing the COVID-19 vaccines was maintaining the cold chain at every step of the distribution process. All vaccines must be stored properly from the time they are manufactured until when they are administered. Storing a vaccine in improper conditions can affect its potency.

COVID-19 vaccines, like other vaccines, have specific temperature requirements for storage and handling. Pfizer’s COVID-19 vaccine required specialized storage and shipping to maintain an ultracold vaccine cold chain (around –70°C (–94°F).

Ensuring that vaccines arrived at their destination while maintaining their ultracold temperature requirements became essential during the most accelerated global vaccination program in history.

Pfizer partnered with Controlant, a company that manufactures devices that show the temperature of the containers, to deliver more than 5 billion COVID-19 vaccines worldwide in specialized shippers like the one displayed.

When the COVID-19 vaccine transitioned in 2023 from a pandemic-era necessity to an annual routine vaccination, the VFC Program updated its storage and handling guidance for routine vaccines to include COVID-19 vaccines.

Sometimes, vaccine providers must move vaccines from one location to another. For example, a pediatric practice with multiple offices may need to move vaccines from one location to another.

The VFC program recommends the use of portable vaccine shippers to ensure that vaccines are kept at the proper temperature when transported short distances.

The program purchased these portable vaccine shippers in the early 2010s as a teaching aid to train providers on what to look for when purchasing their portable vaccine shippers. Soft-sided containers specifically engineered for vaccine transport, such as these, are recommended by the VFC Program.

Vaccines in the Spotlight: The VFC and Vaccination Campaigns

Public health has conducted campaigns to encourage caregivers to vaccinate their children since the 1960s. CDC and its partners ramped up efforts to increase vaccination rates among children after the VFC program launched in 1994.

Vaccination campaigns employed vibrant and engaging methods to capture the attention of young audiences and their caregivers. Campaign materials included colorful posters, catchy slogans, and animated characters to communicate the importance of vaccinations. They emphasized the benefits of vaccines in preventing serious illnesses and protecting individuals and their communities.

VFC campaigns informed caregivers about immunization and encouraged them to participate in protecting the health and well-being of their children. The campaigns normalized vaccination as a familiar and positive aspect of growing up. In doing so, they helped increase immunization rates and improve public health outcomes in the U.S. during the 1990s and 2000s.

Today, CDC, state partners, and non-governmental organizations continue to create fun and inventive communication campaigns to help get all children vaccinated.

Shortly after the launch of the CII Act, CDC partnered with the Ad Council to launch a suite of new communication campaign materials. Posters featuring the message “At Least Eleven Shots by Two” could be found in pediatricians’ offices and on billboards throughout the United States.

Public health has long used public service announcements (PSAs) to broadcast messages about immunization to television screens and radios. Sometimes serious, sometimes playful, the campaign materials always sought to inform caregivers with children about the benefits of immunization.

Each PSA also listed a 1-800 toll-free number that caregivers with children could call to find the nearest site that offered low-cost or free vaccination through the VFC program.

Theodor Seuss Geisel (aka Dr. Seuss, 1921-1990) was a children’s book author, illustrator, and creator of characters such as “The Cat in the Hat.”

Audrey Geisel, the author’s widow, understood the wide appeal of Dr. Seuss’s work. She donated iconic illustrations to the Dr. Seuss Immunization Campaign.

“The Cat in the Hat” was on hand at CDC headquarters in Atlanta on October 30, 1997, to debut the posters. He is joined by Dr. Donna Shalala, Secretary of the Department of Health and Human Services. Each poster features a Dr. Seuss character telling an immunization story in rhyme.

During the 2009 H1N1 pandemic, CDC reported that American Indian and Alaska Native persons (AI/AN) were four times more likely to die from the 2009 H1N1 influenza virus than the general population. One of the causes behind this high mortality rate was limited access to life-saving vaccines.

In 2010, CDC launched the “Life is a Delicate Balance” campaign. The campaign emphasizes how influenza vaccine can protect not only yourself, but also your community. It utilized a trusted messenger approach. Wes Studi, an Oscar award winning actor, producer, and member of the Cherokee Nation, was a spokesperson.

Studi’s involvement in the campaign had important implications for the program. All AI/AN people under 18 years of age qualify for influenza vaccines under the VFC Program.

Today, health departments carry on the work of creating fun and informative information campaigns. This poster created by the Tennessee Department of Health informs people about human papillomavirus (HPV), a vaccine-preventable disease.

In 2007, the Advisory Committee on Immunization Practices (ACIP) recommended that all girls aged 11 or 12 years be vaccinated against HPV. Since then, the VFC program has covered the HPV vaccine. ACIP expanded its recommendation in 2011 to include boys aged 11 or 12 years.

CDC analysis in 2023 showed that for the first time since 2013, HPV vaccination initiation did not increase among adolescents aged 13 to 17 years. HPV vaccination fell among adolescents insured by Medicaid and remained lowest among the uninsured (two of the four groups that constitute the VFC–eligible population). This decrease highlights the continued need for outreach among adolescents eligible for VFC.

Looking Towards the Next 30 Years

Since its inception in 1994, the VFC program has significantly altered the landscape of public health in the U.S. The VFC program has played a pivotal role in increasing vaccination rates and preventing the spread of diseases by providing vaccines at no cost to eligible children.

The VFC program saw huge successes during its first 30 years, but much work remains. As of 2021, only 63% of VFC-eligible children (compared to 76% of non-VFC-eligible children) were up to date with recommended vaccines.

Achieving equitable access to vaccines for all children will require fresh strategies and innovations. One strategy is to enroll new provider locations, including pharmacies, school-based vaccination clinics, and other unconventional sites, in the VFC provider network.

No matter what the future holds, the VFC program will continue to support young families by increasing their access to and confidence in vaccines.

Want to learn more about the history of the VFC Program? Check out the “Vaccines for Children (VFC) Program: A Retrospective of the Program’s First 30 Years” story map.

Credits

“Celebrating 30 Years of Vaccines for Children” was organized and supported by the David J. Sencer CDC Museum, CDC’s Office of Communications, the National Center for Immunization and Respiratory Diseases, the Immunization Services Division, and the Vaccines for Children program. Heather E. Rodriguez curated the exhibition. Alex D. Rogers designed the exhibition.

The organizers would like to extend special thanks to the following individuals and organizations who contributed exhibition materials or helped develop this exhibition.

John Anderton                  Bayo Arthur
Michael Ciaglo                   Tamara Droll
Amanda Dudley                Judy M. Gantt
Sam Graitcer                      Paul Lucas
Jamie Mells                         Llandess Owens
Jeanne Santoli                   California Vaccines for Children Program
Vaccinate Your Family    William J. Clinton Presidential Library and Museum

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