Vaccination Programs: Reducing Client Out-of-Pocket Costs

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to increasing appropriate vaccination.

The systematic review included 20 studies.

• Overall, vaccination rates increased by a median of 22 percentage points (11 studies).
  • Reducing client out-of-pocket costs alone increased vaccination rates by 28 percentage points (6 studies).
  • Reducing client out-of-pocket costs in combination with additional interventions increased vaccination rates by 20 percentage points (5 studies).
• All of the studies that did not provide a common measure of change for vaccination rates reported favorable results (9 studies).

Three studies were included in the economic review (search period 1980 2012). Monetary values are reported in 2013 U.S. dollars.

• Two studies estimated intervention cost for influenza vaccinations.
  • One study estimated the intervention cost was $35 per person per year, resulting in $15,050 per life year saved.
  • One study estimated the intervention cost was $54 per person per year, or $114 per additional person vaccinated.
• The third study used modeling to estimate the effect of eliminating out-of-pocket costs for vaccinations series given to children born in the state of Georgia during 2003. They estimated it would cost $222 per child and $3165 per additional vaccinated child.

• How effective are these interventions for adolescent populations?
• Does reducing client out-of-pocket costs work to increase rates of annual influenza vaccinations?
• Are these interventions an essential component of school-based vaccination programs or on-site vaccination programs in general?

• Included studies evaluated intervention effects on uptake of childhood vaccination series (3 studies), influenza (9 studies), pneumococcal (6 studies), hepatitis B (2 studies), and human papilloma virus (1 study).
• Studies were conducted in a range of client and provider populations and settings.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

No content is available for this section.

Effectiveness Review

Al-Sukhni W, Avarino P, McArthur MA, McGeer A. Impact of public vaccination programs on adult vaccination rates: two examples from Ontario, Canada. Vaccine 2008;26(11):1432-7.

Andrews RM, Skull SA, Byrnes GB, Campbell DA, Turner JL, McIntyre PB et al. Influenza and pneumococcal vaccine coverage among a random sample of hospitalised persons aged 65 years or more, Victoria. Communicable Diseases Intelligence 2005;29:283-8.

Banach DB, Ornstein K, Factor SH, Soriano TA. Seasonal influenza vaccination among homebound elderly receiving home-based primary care in New York City. Journal of Community Health 2012;37(1):10-4.

Carpenter LR, Lott J, Lawson BM, Hall S, Craig AS, Schaffner W et al. Mass distribution of free, intranasally administered influenza vaccine in a public school system. Pediatrics 2007;120(1):e172-8.

Chang ET, Sue E, Zola J, So SK. 3 For Life: a model pilot program to prevent hepatitis B virus infection and liver cancer in Asian and Pacific Islander Americans. American Journal of Health Promotion 2009;23(3):176-81.

Chen CS, Liu TC. The Taiwan National Health Insurance program and full infant immunization coverage. American Journal of Public Health 2005;95(2):305-11.

Crosby RA, Casey BR, Vanderpool R, et al. Uptake of free HPV vaccination among young women: a comparison of rural versus urban rates. Journal of Rural Health 2011;27(4):380-4.

Durando P, Crovari P, Ansaldi F, et al. Universal childhood immunisation against Streptococcus pneumoniae: the five-year experience of Liguria Region, Italy. Vaccine 2009;27(25-26):3459-62.

Florida Medical Quality Assurance. Influenza immunization among Medicare beneficiaries enrolled in a health maintenance organization: 1994. Florida Medical Quality Assurance, Inc. Journal of the Florida Medical Association 1998;85(1):19-20.

Freed GL, Clark SJ, Pathman DE, Schectman R, Serling J. Impact of North Carolina’s universal vaccine purchase program by children’s insurance status. Archives of Pediatrics & Adolescent Medicine 1999;153 (7):748-54.

Humair JP, Buchs CR, Stalder H. Promoting influenza vaccination of elderly patients in primary care. Family Practice 2002;19(4):383-9.

Kleschen MZ, Holbrook J, Rothbaum AK, Stringer RA, McInerney MJ, Helgerson SD. Improving the pneumococcal immunization rate for patients with diabetes in a managed care population: a simple intervention with a rapid effect. Joint Commission Journal on Quality Improvement 2000;26(9):538-46.

Malmvall BE, Franzen I, Abom PE, Hugosson MB. The rate of influenza immunization to people aged 65 years and older was increased from 45% to 70% by a primary health care-based multiprofessional approach. Qual Manag Health Care 2007;16(1):51-9.

Middleman AB. Race/ethnicity and gender disparities in the utilization of a school-based hepatitis B immunization initiative. J Adolesc Health 2004; 34(5):414-9.

Racine AD, Joyce TJ. Maternal education, child immunizations, and public policy: Evidence from the US National Immunization Survey. Soc Sci Med 2007;65(8):1765-72.

Ridda I, MacIntyre RC, Lindley RI, McIntyre PB, Sullivan J, Gilbert G et al. Predictors of pneumococcal vaccination uptake in hospitalized patients aged 65 years and over shortly following the commencement of a publicly funded national pneumococcal vaccination program in Australia. Human Vaccines 2007;3(3):83-6.

Vila-Corcoles A, Ochoa-Gondar O, Ester F, Sarra N, Ansa X, Saun N et al. Evolution of vaccination rates after the implementation of a free systematic pneumococcal vaccination in Catalonian older adults: 4-years follow-up. BMC Public Health 2006; 6:231.

Weir R, Jennings L, Brunton C. Influenza vaccination coverage in Canterbury rest homes. New Zealand Medical Journal 2000;113(1122):503-5.

Wiggs-Stayner KS, Purdy TR, Go GN, Mclaughlin NC, Tryzynka PS, Sines JR et al. The impact of mass school immunization on school attendance. Journal of School Nursing 2006;22(4);219-22.

Zimmerman RK, Nowalk MP, Raymund M, Tabbarah M, Hall DG, Wahrenberger JT et al. Tailored interventions to increase influenza vaccination in neighborhood health centers serving the disadvantaged. American Journal of Public Health 2003;93 (10):1699-705.

Economic Review

Hoshi SL, Kondo M, Honda Y, Okubo I. Cost-effectiveness analysis of influenza vaccination for people aged 65 and over in Japan. Vaccine 2007;25(35):6511-21. http://dx.doi.org/10.1016/j.vaccine.2007.05.067.

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Effectiveness Review

The CPSTF findings are based on studies included in the original review (search period 1980-1997) combined with studies identified in the updated search (search period 1997- February 2012). Reference lists of articles reviewed as well as lists in review articles were also searched, and members of our coordination team were consulted for additional references.

Details of the original search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included in the review, a study had to:

• have a publication date of 1980 1997;
• address universally recommended adult, adolescent, or childhood vaccinations;
• be a primary study rather than, for example, a guideline or review;
• take place in an industrialized country or countries;
• be written in English;
• meet the evidence review and Guide chapter development team’s definition of the interventions; provide information on one or more outcomes related to the analytic frameworks; and
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

Details of the update search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing the effectiveness of Vaccine Preventable Disease interventions in improving vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. Reference lists of articles reviewed as well as lists in review articles were also searched, and subject matter experts consulted for additional references. To be included in the updated review, a study had to:

• have a publication date of 1997- February 2012;
• evaluate vaccinations with universal recommendations;
• meet the evidence review and Guide chapter development team’s definition of the interventions;
• be a primary research study with one or more outcomes related to the analytic frameworks;
• take place in an high income country or countries;
• be written in English
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive

Search Terms

1. Immunization
2. Vaccination
3. Immunization Programs

Economic Review

The present review included studies that reported economic outcomes from the 2000 review (search period 1980-1997) combined with studies identified from updated searches (search period 1997- February 2012) within the standard medical and health-related research databases, Google Scholar, and databases specialized to economics and social sciences. The details of the two sets of searches are provided below.

Details of the Updated Search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing interventions to improve vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. In addition, Google Scholar and specialized databases (CRD-University of York: NHS EED, EconLit, and JSTOR), were also searched. Reference lists of articles reviewed as well as lists in review articles were also considered, and subject matter experts consulted for additional references.

Search Terms

• Immunization
• Vaccination
• Immunization Programs

To be included in the updated review, a study had to do the following:

• Have a publication date of 1997- February 2012
• Evaluate vaccinations with universal recommendations
• Meet the evidence review and Community Guide review team’s definition of the interventions
• Be a primary research study with one or more outcomes related to the analytic framework(s)
• Take place in a high income country or countries
• Be written in English; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed.

Details of the Original Search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included, a study had to do the following:

• Have a publication date of 1980 1997
• Address universally recommended adult, adolescent, or childhood vaccinations
• Be a primary study rather than, for example, a guideline or review
• Take place in an industrialized country or countries
• Be written in English
• Meet the definition of the interventions
• Provide information on one or more outcomes related to the analytic frameworks; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

• Policies adopted in the United States, including the Federal Vaccines for Children Program and the Affordable Care Act, have expanded access to many vaccines by reducing out-of-pocket cost for clients.
• The ability of healthcare systems and providers to implement these interventions may depend on how well and how quickly they are reimbursed for the costs of the vaccines, storage, and administration.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children who get no recommended vaccines by age 2 years — IID‑02
• Maintain the vaccination coverage level of 1 dose of the MMR vaccine in children by age 2 years — IID‑03
• Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten — IID‑04
• Increase the coverage level of 4 doses of the DTaP vaccine in children by age 2 years — IID‑06
• Increase the proportion of people who get the flu vaccine every year — IID‑09
• Increase the proportion of adults age 19 years or older who get recommended vaccines — IID‑D03