Vaccination Programs: Special Supplemental Nutrition Program for Women, Infants & Children (WIC) Settings

The CPSTF finding is based on evidence from a Community Guide systematic review completed in 2009 (15 studies, search period January 1980-November 2009). A more recent search for evidence (search period 2009-February 2012) did not identify any new studies to be included in the systematic review.

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.

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The systematic review included 15 studies.

• Overall, vaccination rates among children increased by a median of 10.5 percentage points (8 studies with 10 study arms).
• One study evaluated the use of interventions used alone and found no effect.
• The additional interventions most often used were monthly voucher pickup (5 studies) and vaccine administration on-site or in collocated healthcare facilities (4 studies).

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The economic evidence is based on three studies that looked at the childhood vaccination series (search period 1980 2012). Monetary values are presented in 2013 U.S. dollars.

• Intervention cost per child per year averaged $17.77. The cost per vaccinated child averaged $67.96 (2 studies).
  • Cost estimates varied because interventions were for monthly voucher pickup programs that used different referral types or included additional monitoring.
• The third study provided an incomplete estimate for intervention cost, reporting only the cost of assessment for age-appropriate vaccination status (range: $1.90 to $3.93). The higher cost was attributed to the addition of an on-site nurse.

The CPSTF finding should be applicable to most WIC settings and populations.

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 effectiveness are intervention when implemented alone?
• What are the effects of collocating WIC and health care services, requiring monthly voucher pickup, or providing WIC interventions outside of the medical home?

• All of the included studies evaluated WIC programs in urban settings and populations.

Jacob V, Chattopadhyay SK, Hopkins DP, Murphy-Morgan J, Pitan AA, Clymer JM, Community Preventive Services Task Force. Increasing coverage of appropriate vaccinations: a Community Guide systematic economic review. American Journal of Preventive Medicine 2016;50(6):797–808.

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.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained n several publications).

Effectiveness Review

Ashkar SH, Dales LG, Averhoff F et al. The effectiveness of assessment and referral on immunization coverage in the special supplemental nutrition program for women, infants, and children. Archives of Pediatrics & Adolescent Medicine 2003;157:456-62.

Bardenheier BH, Yusuf HR, Rosenthal J et al. Factors associated with underimmunization at 3 months of age in four medically underserved areas. Public Health Reports 119(5):479-85.

Birkhead GS, LeBaron CW, Parsons P, Grabau JC, Maes E, Barr-Gale L et al. The immunization of children enrolled in the Special Supplemental Food Program for Women, Infants, and Children (WIC). The impact of different strategies. JAMA 1995;274(4):312-31.

Brenner RA, Simons-Morton BG, Bhaskar B, Das A, Clemens JD, NIH DCI. Prevalence and predictors of immunization among inner-city infants: a birth cohort study. Pediatrics 2001;108(3):661-70.

Cortese MM, Diaz PS, Samala U et al. Underimmunization in Chicago children who dropped out of WIC. American Journal of Preventive Medicine 2004;26(1):29-33.

Dietz VJ, Baughman AL, Dini EF, Stevenson JM, Pierce BK, Hersey JC. Vaccination practices, policies, and management factors associated with high vaccination coverage levels in Georgia public clinics. Georgia Immunization Program Evaluation Team. Archives of Pediatrics & Adolescent Medicine 2000;154(2):184-9.

Ghosh TS, Patnaik JL, Bennett A, Trefren L, Vogt RL. Assessment of missing immunizations and immunization-related barriers among WIC populations at the local level. Public Health Rep 2007;122(5):602-6.

Golden R. Voucher incentives to increase childhood immunization rates [comment]. JAMA 1999;281(8):702-3.

Hoekstra EJ, LeBaron CW, Megaloeconomou Y et al. Impact of a large-scale immunization initiative in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) [see comment]. JAMA 1998;280(13):1143-7.

Hoekstra EJ, LeBaron CW, Johnson PT. Does reminder-recall augment the impact of voucher incentives on immunization rates among inner-city infants enrolled in WIC? Special Supplemental Program for Women, Infants, and Children. Journal of Pediatrics 1999;135:261-3.

Hutchins SS, Rosenthal J, Eason P, Swint E, Guerrero H, Hadler S. Effectiveness and cost-effectiveness of linking the special supplemental program for women, infants, and children (WIC) and immunization activities. Journal of Public Health Policy 1999;(4):408-26.

Kendal AP, Neville LJ, Manning CC. Optimal immunization practices for the special supplemental nutrition program for women, infants, and children. American Journal of Public Health 2000;90(10):1640-1.

Shefer AM, Luman ET, Lyons BH et al. Vaccination status of children in the Women, Infants, and Children (WIC) Program: are we doing enough to improve coverage? American Journal of Preventive Medicine 2001;(4 Suppl):47-54.

Shefer AM, Fritchley J, Stevenson J et al. Linking WIC and immunization services to improve preventive health care among low-income children in WIC. Journal of Public Health Management & Practice 2002;8(2):56-65.

Suarez L, Simpson DM, Smith DR. The impact of public assistance factors on the immunization levels of children younger than 2 years. American Journal of Public Health 1997;87(5):845-8.

Waterman SH, Hill LL, Robyn B, Yeager KK, Maes EF, Stevenson JM et al. A model immunization demonstration for preschoolers in an inner-city barrio, San Diego, California, 1992-1994. Am J Prev Med 1996;12(4 Suppl):8-13.

Economic Review

Flatt K, Watson JC, Anderson KN, Logan L, Nguyen V. A cost comparison of methods used to increase immunization levels in a WIC setting. Paper presented at: The 124th annual meeting and exposition of the American Public Health Association, November 17-21. 1996; New York.

Hoekstra EJ, LeBaron CW, Megaloeconomou Y, et al. Impact of a large-scale immunization initiative in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). JAMA 1998;280(13):1143. http://dx.doi.org/10.1001/jama.280.13.1143.

Hutchins SS, Rosenthal J, Eason P, Swint E, Guerrero H, Hadler S. Effectiveness and cost-effectiveness of linking the special supplemental program for women, infants, and children (WIC) and immunization activities. J Public Health Policy 1999:408-26. http://dx.doi.org/10.2307/3343128.

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 following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• WIC services provide opportunities for regular and ongoing contact with families who may have limited access or substantial barriers to vaccination services.
• On-site or collocation of vaccination services can greatly enhance access. They require ongoing communication and coordination between WIC programs and healthcare providers to minimize missed vaccination opportunities and maintain continuity of care.

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