Vaccination Programs: Community-Based Interventions Implemented in Combination

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 18 studies with 21 study arms.

• Overall vaccination rates: median increase of 14 percentage points (18 studies)
  • Older adults (65 years and older): median increase of 30.8 percentage points (4 studies)
  • Children (12 years and younger): median increase of 12 percentage points (14 studies)
• Studies that combined one or more interventions to increase client and community demand with one or more interventions to enhance access to vaccination services saw a median increase in vaccination rates of 16 percentage points (14 studies).
• Intervention combinations that included client reminders reported a median increase in vaccination rates of 13 percentage points (15 study arms).

Twenty-two studies that qualified for the economic review evaluated combinations of community-based interventions, such as client reminders, mass media, home visits, and client incentives. All monetary values provided are in 2012 U.S. dollars.

• Estimates of cost and cost-effectiveness varied between studies.
  • The median intervention cost per person per year was $54 (19 studies).
  • The median cost per additional vaccinated person was $461 (19 studies)
  • Estimates were higher for combined interventions that included intensive outreach and home visits.
  • Estimates were lower for combined interventions that were mostly based on mail or telephone reminders.

• Populations with low vaccination rates
  • Children ages 12 years and younger
  • Older adults ages 65 years and older
  • Groups with low socioeconomic status
  • Racial and ethnic minorities
• Different vaccines, including
  • Recommended childhood series
  • Pneumococcal adults
  • Influenza adults
• Urban areas

• How effective are these programs when applied to adolescents, or in rural settings?
• What are the economic efficiencies of the more resource-intensive components (i.e., manual outreach and tracking, home visits)?
• How does program effectiveness differ based on included component interventions and strategic combinations?
• What are the most efficient ways to sustain these programs, especially for existing community-based organizations?

• In 13 of the 18 studies, the community-based effort combined one or more interventions to increase community demand for vaccinations with one or more interventions to enhance access to vaccination services.
• Interventions were conducted in urban (21 study arms) and rural (1 study arm) settings.
• Interventions targeted children (21 study arms), adolescents (1 study arm) and adults (4 study arms).
• Studies evaluated the following vaccines:
  • Recommended childhood series (15 study arms)
  • Influenza adults (4 study arms)
  • Pneumococcal adults (2 study arms)
  • Hepatitis B child (1 study arm)
• Majority of the studies evaluated interventions that targeted populations with low socioeconomic status (10 study arms).

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.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

Summary Evidence Table – Economic Review

Effectiveness Review

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Bond LM, Nolan TM, Lester RA. Home vaccination for children behind in their immunisation schedule: a randomised controlled trial. Medical Journal of Australia 1998;168(10):487-90.

Dalby DM, Sellors JW, Fraser FD, Fraser C, van IC, Howard M. Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial. Canadian Medical Association Journal 2000;162:497-500.

Daniels NA, Juarbe T, Moreno-John G, Perez-Stable EJ. Effectiveness of adult vaccination programs in faith-based organizations. Ethnicity & Disease 2007;17(Suppl 1):S15-22.

Etkind P, Simon M, Shannon S, et al. The impact of the medicare influenza demonstration project on inlfuenza vaccination in a county in Massachusetts, 1988 1992. Journal of Community Health 1996;21(3):199-209.

Findley SE, Irigoyen M, Sanchez M, et al. Effectiveness of a community coalition for improving child vaccination rates in New York City. American Journal of Public Health 2008;98(11):1959-62.

Findley SE, Sanchez M, Mejia M, et al. Effective strategies for integrating immunization promotion into community programs. Health Promotion Practice 2009;10(Suppl 2):128S-137S.

Goldstein KP, Lauderdale DS, Glushak C, Walter J, Daum RS. Immunization outreach in an inner-city housing development: reminder-recall on foot. Pediatrics 1999;104(6):e69.

LeBaron CW, Starnes D, Dini EF, Chambliss JW, Chaney M. The impact of interventions by a community-based organization on inner- city vaccination coverage: Fulton County, Georgia, 1992-1993. Archives of Pediatrics and Adolescent Medicine 1998;152(4):327-32.

LeBaron CW, Starnes DM, Rask KJ. The Impact of Reminder-Recall Interventions on Low Vaccination Coverage in an Inner-City Population. Archives of Pediatrics and Adolescent Medicine 2004;158(3):255-61.

Lemstra M, Rajakumar D, Thompson A, Moraros J. The effectiveness of telephone reminders and home visits to improve measles, mumps and rubella immunization coverage rates in children. Paediatrics and Child Health 2011;16(1):e1-e5.

Ohmit SE, Furumoto-Dawson A, Monto AS, Fasano N. Influenza vaccine use among an elderly population in a community intervention. American Journal of Preventive Medicine 1995;11(4):271-6.

Paunio M, Virtanen M, Peltola H, et al. Increase of vaccination coverage by mass media and individual approach: intensified measles, mumps, and rubella prevention program in Finland. American Journal of Epidemiology 1991;133(11):1152.

Rodewald LE, Szilagyi PG, Humiston SG, Barth R, Kraus R, Raubertas RF. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics 1999;103(1):31-8.

Stevens SC, Kelly L, Brayden RM. A health passport for adolescent parents and their children. Clinical Pediatrics 2001;40:169-72.

Szilagyi PG, Schaffer S, Shone L, et al. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics 2002;110(5):e58.

Vora S, Verber L, Potts S, Dozier T, Daum RS. Effect of a novel birth intervention and reminder-recall on on-time immunization compliance in high-risk children. Human Vaccines 2009;5(6):395-402.

Wood D, Halfon N, Donald-Sherbourne C, et al. Increasing immunization rates among inner-city, African American children: A randomized trial of case management. Journal of the American Medical Association 1998;279(1):29-34.

Yokley JM, Glenwick DS. Increasing the immunization of preschool children; an evaluation of applied community interventions. Journal of Applied Behavior Analysis 1984;17(3):313.

Economic Review

Bond LM, Nolan TM, Lester RA. Home vaccination for children behind in their immunisation schedule: a randomised controlled trial. Med J Aust 1998;168(10):487-490.

Browngoehl K, Kennedy K, Krotki K, Mainzer H. Increasing immunization: a Medicaid managed care model. Pediatrics 1997;99(1):e4. http://dx.doi.org/10.1542/peds.99.1.e4.

Deuson RR, Brodovicz KG, Barker L, Zhou F, Euler GL. Economic analysis of a child vaccination project among Asian Americans in Philadelphia, PA. Arch Pediatr Adolesc Med 2001;155(8):909-14. http://dx.doi.org/10.1001/archpedi.155.8.909.

El-Mohandes AAE, Katz KS, El-Khorazaty MN, et al. The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: a randomized, controlled study. Pediatrics 2003;111(6):1324. http://dx.doi.org/10.1542/peds.111.6.1324.

Greengold B, Nyamathi A, Kominski G, et al. Cost-effectiveness analysis of behavioral interventions to improve vaccination compliance in homeless adults. Vaccine 2009;27(5):718-25. http://dx.doi.org/10.1016/j.vaccine.2008.11.031.

Hand JS, Anderson D, Feffer D, Day C. A successful school immunization program–or not? J Sch Health 1980;50(1):50. http://dx.doi.org/10.1111/j.1746-1561.1980.tb03888.x.

Hoekstra EJ, LeBaron CW, Johnson-Partlow TLD. Does reminder-recall augment the impact of voucher incentives on immunization rates among inner-city infants enrolled in WIC? J Pediatr 1999;135(2 Part 1):261. http://dx.doi.org/10.1016/S0022-3476(99)70033-8.

Kansagra SM, McGinty MD, Morgenthau BM, et al. Cost comparison of 2 mass vaccination campaigns against influenza A H1N1 in New York City. Am J Public Health 2011;102(7):1378-83. http://dx.doi.org/10.2105/AJPH.2011.300363.

LeBaron CW, Starnes D, Dini EF, Chambliss JW, Chaney M. The impact of interventions by a community-based organization on inner-city vaccination coverage: Fulton County, Georgia, 1992-1993. Arch Pediatr Adolesc Med 1998;152(4):327. http://dx.doi.org/10.1001/archpedi.152.4.327.

Moran WP, Nelson K, Wofford JL, Velez R, Case LD. Increasing influenza immunization among high-risk patients: education or financial incentive? Am J Med 1996;101(6):612-20. http://dx.doi.org/10.1016/S0002-9343(96)00327-0.

Paunio M, Virtanen M, Peltola H, et al. Increase of vaccination coverage by mass media and individual approach: intensified measles, mumps, and rubella prevention program in Finland. Am J Epidemiol 1991;133(11):1152.

Rask KJ, LeBaron CW, Starnes DM. The costs of registry-based immunization interventions. Am J Prev Med 2001;21(4):267-271. http://dx.doi.org/10.1016/S0749-3797(01)00370-1.

Rodewald LE, Szilagyi PG, Humiston SG, Barth R, Kraus R, Raubertas RF. A randomized study of tracking with outreach and provider prompting to improve immunization coverage and primary care. Pediatrics 1999;103(1):31-38. http://dx.doi.org/10.1542/peds.103.1.31.

Sander B, Kwong JC, Bauch CT, et al. Economic appraisal of Ontario’s Universal Influenza Immunization Program: a cost-utility analysis. PLoS Med 2010;7(4):e1000256. http://dx.doi.org/10.1371/journal.pmed.1000256.

Seal KH, Kral AH, Lorvick J, McNees A, Gee L, Edlin BR. A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users. Drug Alcohol Depend 2003;71(2):127-31. http://dx.doi.org/10.1016/S0376-8716(03)00074-7.

Szilagyi PG, Humiston SG, Gallivan S, Albertin C, Sandler M, Blumkin A. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Arch Pediatr Adolesc Med 2011;165(6):547. http://dx.doi.org/10.1001/archpediatrics.2011.73.

Szilagyi PG, Schaffer S, Shone L, et al. Reducing geographic, racial, and ethnic disparities in childhood immunization rates by using reminder/recall interventions in urban primary care practices. Pediatrics 2002;110(5):e58. http://dx.doi.org/10.1542/peds.110.5.e58.

Vora S, Verber L, Potts S, Dozier T, Daum RS. Effect of a novel birth intervention and reminder-recall on on-time immunization compliance in high-risk children. Hum Vaccin 2009;5(6):395. http://dx.doi.org/10.4161/hv.5.6.7282.

Westman S, Halbert RJ, Walton LG, Henneman CE. A clinic without walls: the Los Angeles Immunization Demonstration Project. Am J Public Health 1997;87(2):293-4.

Wood D, Halfon N, Donald-Sherbourne C, et al. Increasing immunization rates among inner-city, African American children. JAMA 1998;279(1):29. http://dx.doi.org/10.1001/jama.279.1.29.

Yokley JM, Glenwick DS. Increasing the immunization of preschool children; an evaluation of applied community interventions. J Appl Behav Anal 1984;17(3):313. http://dx.doi.org/10.1901/jaba.1984.17-313.

Zhou F, Euler GL, McPhee SJ, et al. Economic analysis of promotion of hepatitis B vaccinations among Vietnamese-American children and adolescents in Houston and Dallas. Pediatrics 2003;111(6):1289-96. http://dx.doi.org/10.1542/peds.111.6.1289.

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.

• Program planners should consider community characteristics, such as mobility and fragmentation of health care, when selecting interventions.
• Partnerships between community organizations and vaccination providers are likely to be essential components of effective, sustained community-based efforts.
• Intensive combinations of interventions (e.g. home visits, monetary and in-kind incentives) may be necessary to increase vaccination rates in populations that continue to have low rates of immunization after less intensive methods (e.g. client reminders, provider reminders) have been implemented.

Evidence-Based Cancer Control Programs (EBCCP)

Find programs from the EBCCP website that align with this systematic review. (What is EBCCP?)

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