Special Medical Reports

Task Force Outlines Ways to Improve Vaccination Coverage

Am Fam Physician. 1999 Nov 15;60(8):2431-2432.

The Task Force on Community Preventive Services has developed recommendations for interventions to improve vaccine coverage in children, adolescents and adults. The recommendations were developed to help communities achieve high levels of vaccination coverage and low rates of vaccine-preventable diseases. The task force is an independent, non-federal entity, although it receives support from the Department of Health and Human Services and the Centers for Disease Control and Prevention. The task force's recommendations for ways to improve vaccination coverage will be included in a chapter of the Guide to Community Preventive Services, a book that is being developed by the task force.

A report of the task force's recommendations for improving vaccination coverage is published in the June 18, 1999 issue of the recommendations and reports series of Morbidity and Mortality Weekly Report. Task force members identified 17 interventions that may improve routine delivery of universally recommended vaccinations. A systematic review of the literature was performed to analyze data on these interventions. The task force then formulated recommendations—categorized as “strongly recommended,” “recommended” and “insufficient evidence”—regarding the use of these interventions. The following summarizes the recommendations for the 17 interventions.

Strongly Recommended Interventions

The following interventions were given the classification of “strongly recommended” by the task force.

  • Client reminder/recall systems. Reminders that vaccinations are due or late can be accomplished by telephone calls, letters or postcards. Studies show that reminders improve vaccination coverage in children and adults. They are effective in individual practice settings and across entire community settings.

  • Multicomponent interventions that include education. Target populations as well as vaccination providers might receive education. Education along with another vaccine-related activity has been found to improve vaccination coverage in communitywide and practice settings.

  • Reducing out-of-pocket costs. Access to vaccination services can be enhanced by providing free vaccinations or insurance coverage of vaccinations or by reducing copayments at the point of service. This intervention is effective when applied in a clinic setting, statewide or nationwide.

  • Expanding access in medical or public health clinical settings. The report states that there is insufficient evidence to recommend this intervention alone; however, it is strongly recommended as part of a multicomponent intervention. Expanding access can be accomplished, for example, by reducing the distance between the clinical setting and the population, making the hours more convenient. “Drop-in” clinics or “express lane” vaccination services are other examples of ways to expand access.

  • Provider reminder/recall. Reminders for clinicians can be delivered in medical charts, by computer, by mail, etc. This intervention has been shown to improve vaccination coverage and can be implemented with flowcharts, checklists or simple reminders.

  • Assessment and feedback for vaccination providers. Retrospective evaluation of the performance of providers in delivering vaccinations to a population can provide important information and can increase vaccination coverage.

  • Standing orders. Allowing medical personnel who are not physicians to provide vaccinations by protocol, without direct physician involvement, can improve vaccination coverage and is strongly recommended for adults. The report states that the evidence is insufficient for recommending such a practice in children. Standing orders can be implemented in clinics, hospitals and nursing homes.

Recommended Interventions

The following interventions were given the classification of “recommended” by the task force.

  • Vaccination requirements for child care, school and college attendance. Laws or policies that mandate vaccination are effective in reducing vaccine-preventable disease and improving vaccination coverage in relevant populations.

  • Vaccination programs in Women, Infants and Children (WIC) settings. Vaccination programs in WIC programs and other nonmedical settings are helpful for persons of low income. Studies of this type of intervention have included on-site vaccination and referral elsewhere for vaccination. Education, provision of vaccinations and incentives to accept vaccinations can be a part of this intervention.

  • Home visits. Services can include education, assessment of the need for vaccinations, referral or provision of vaccinations. Most of the studies of this approach have been conducted in socioeconomically disadvantaged populations.

Insufficient Evidence for Recommending the Intervention

The report notes that a determination that evidence is insufficient for making a recommendation for an intervention does not necessarily signify that the intervention is ineffective. Rather, this classification identifies areas of uncertainty about the effectiveness of an intervention because of the small number of studies that examined the intervention. It also reflects areas for which research is needed. The following interventions were categorized as having “insufficient evidence” by the task force.

  • Communitywide education only and clinic-based education only. Communitywide activities can provide information to a target population. No studies were found that evaluated the effectiveness in changing individuals' knowledge and attitudes about vaccinations, and no studies have evaluated anything other than printed material. Variable effects were found in two studies that evaluated the impact of vaccination information statements on knowledge and attitudes about vaccination.

  • Client or family incentives. Financial or other incentives may serve to motivate acceptance of vaccinations. Incentives can be rewards or penalties. Only three studies of this intervention were identified. One study found that incentives did not result in a statistically significant change in vaccination coverage.

  • Client-held medical records. This intervention gives the records that indicate which vaccinations have not been received by family members or patients. Effectiveness of this approach has been variable in clinical studies.

  • Vaccination programs in schools. Only one study of this intervention was identified, and it did not provide comparative data on vaccination outcomes.

  • Vaccination programs in child care centers. Only one study was identified and it did not meet the task force's criteria for inclusion.

  • Provider education only. Techniques for educating vaccination providers can include written materials, videos, lectures and continuing medical education programs. Only four studies were identified. Three studies demonstrated variable effects of education on providers' knowledge and attitudes. The study with the most intensive intervention documented improvements in the knowledge and attitude of providers.

Use of the Recommendations in Communities and Health Care Systems

According to the report of the Task Force on Community Preventive Services, a starting point for remedying the problems of inadequate vaccination coverage in communities and health care systems is to assess current activities. The causes of underimmunization should be assessed and interventions implemented to correct the problem. Whether special attention is warranted for high-risk populations should also be assessed. According to the report, improving the vaccination coverage of poor persons in urban settings should be a top priority.


Copyright © 1999 by the American Academy of Family Physicians.
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