Vaccination Programs: Health Care System-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 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)

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.

• 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

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

• 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).

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

Summary Evidence Table – Economic Review

Effectiveness Review

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Warner EA, Seleznick MJ. Using medical record reminders to improve pneumococcal vaccination rates. Joint Commission Journal on Quality & Patient Safety 2004;30(6):331-4.

Zimmerman RK, Hoberman A, Nowalk MP, et al. Improving influenza vaccination rates of high-risk inner-city children over 2 intervention years. Annals of Family Medicine 2006;4(6):534-40.

Economic Review

Ahmed F, Elbasha EE, Thompson BL, Harris JR, Sneller VP. Cost-benefit analysis of a new HEDIS performance measure for pneumococcal vaccination. Med Decis Making 2002;22(Suppl 1):s58-s66. http://dx.doi.org/10.1177/027298902237711.

Frame PS, Zimmer JG, Werth PL, Hall WJ, Eberly SW. Computer-based vs manual health maintenance tracking: a controlled trial. Arch Fam Med 1994;3(7):581. http://dx.doi.org/10.1001/archfami.3.7.581.

Hambidge SJ, Phibbs SL, Chandramouli V, Fairclough D, Steiner JF. A stepped intervention increases well-child care and immunization rates in a disadvantaged population. Pediatrics 2009;124(2):455. http://dx.doi.org/10.1542/peds.2008-0446.

Healy CM, Rench MA, Baker CJ. Implementation of cocooning against pertussis in a high-risk population. Clin Infect Dis 2011;52(2):157. http://dx.doi.org/10.1093/cid/ciq001.

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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.

The CPSTF also recommends community-based interventions implemented in combination giving decision-makers a range of options to consider when selecting and coordinating interventions to meet local needs and resources.

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