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Vaccination Programs: Health Care System-Based Interventions Implemented in Combination


What the CPSTF Found

About The Systematic Review

The CPSTF finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). It updates and replaces the 2010 finding for Health System-Based Interventions Implemented in Combination pdf icon [PDF - 611 KB].

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.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 173 KB].

The systematic review included 64 studies with 76 study arms.

  • Overall change in vaccination rates from the combination of at least two interventions: median increase of 9.0 percentage points (58 studies with 70 study arms)
    • Increases in vaccination rates were larger when implemented in settings with low rates at baseline.
  • Change in vaccination rates from the combination of at least one intervention each from two or more strategies: median increase of 17.0 percentage points (37 studies with 44 study arms)

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 173 KB].

The five studies included in the economic review assessed various combinations of provider reminders, standing orders, provider assessment and feedback, provider education, and provider incentives. All monetary values are reported in 2012 U.S. dollars.

  • The median intervention cost per person per year was $4 (4 studies)
  • The mean cost per additional vaccinated person was $12 (3 studies)
  • One study evaluated an intensive intervention that included home visits to immunize and care for newborns. The cost reported in this study is considered an outlier and was not included in the cost estimates provided above.


Based on evidence from the review, the CPSTF finding should be applicable to the following:

  • A range of clinical settings, communities, and client populations
  • Children ages 12 years and younger
  • Adults ages 18 to 65 years
  • Older adults ages 65 years and older
  • Urban settings
  • Different vaccines, including
    • Childhood series
    • Pneumococcal—adults and children
    • Influenza—adults and children
    • Tetanus booster

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

  • How effective are interventions when applied to adolescents, or in rural settings?
  • What are the effects of long-term quality improvement efforts?

Study Characteristics

  • Studies were conducted in urban (34 study arms), rural (1 study arm), and mixed urban, suburban, and rural (9 study arms) settings.
  • Interventions targeted children (29 study arms), adolescents (2 study arms), adults (14 study arms), and older adults (22 study arms).
  • Studies evaluated the following vaccines:
    • Influenza—child (5 study arms)
    • Influenza—adult (27 study arms), child (1 study arm)
    • Pneumococcal—adult (19 study arms)
    • Tetanus booster (4 study arms)
    • Vaccines recommended for children (24 study arms)
    • Vaccines recommended for adolescents (1 study arm)
  • Nearly one-third of the studies evaluated interventions that targeted populations with low socioeconomic status (22 study arms).