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Am Fam Physician. 2005;72(2):338-339

The Task Force on Community Preventive Services of the Centers for Disease Control and Prevention (CDC) has issued an evidence-based review of interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults younger than 65 years. The recommendations were based on a systematic review. The full report appears in the April 1, 2005, issue of Morbidity and Mortality Weekly Report and is available online athttp://www.cdc.gov/mmwr/PDF/rr/rr5405.pdf.

Influenza, pneumococcal infections, and hepatitis B cause substantial morbidity and mortality in the United States, especially among persons at high risk (e.g., those with certain medical conditions, occupational exposures, or risky behaviors). Reducing the incidence of these diseases is highly dependent on increasing vaccination coverage among high-risk adults. Although vaccines are effective and widely available, vaccination rates remain low.

The task force performed a systematic review to evaluate the efficacy of interventions used alone or in combination to increase vaccination coverage among high-risk adults younger than 65 years. The review addressed three vaccinations recommended for high-risk adults (i.e., influenza, pneumococcal polysaccharide, and hepatitis B). Intervention categories included enhancing access to vaccination services, providing physician- and system-based interventions, and increasing community and patient demand.

Results

INTERVENTION

Although the task force found insufficient evidence to support the efficacy of interventions when used alone, they found that multicomponent interventions may improve coverage rates. Multicomponent interventions reinforce one another, because a patient who receives one intervention may be more receptive to others. Also, multicomponent interventions are more intense than single-component interventions and increase the likelihood that a patient will be exposed to at least one intervention. Specific interventions include:

  • Expanded access in health care settings

  • Reducing patients’ out-of-pocket costs

  • Standing orders

  • Physician or patient reminder systems and education

  • Physician assessment and feedback

The task force recommends combining at least one intervention aimed at enhancing access to targeted vaccination services with at least one physician- or system-based intervention and/or at least one intervention to increase patient demand for vaccination. The accompanying table lists the recommended combinations.

At least one of the following interventions to enhance access to vaccination services
Expanded access in health care settings
Reducing patients’ out-of-pocket costs
plus
At least one of the following physician- or system-based interventions
Standing orders
Physician reminder systems
Physician assessment and feedback
and/or
At least one of the following interventions to increase patient demand for vaccination services
Patient reminder systems
Patient education

Physician reminders are the only interventions that may effectively improve coverage rates when used alone.

IMPLEMENTATION

Community Matching

Implementing interventions that best fit the community’s needs and resources is important. Program planning and community assessment should take place before implementing an intervention plan. When matching interventions to local needs, planners should assess existing disparities in vaccine coverage among adult patients with universal and targeted indications. The interventions may also be modified to address barriers to vaccination, although more research is needed.

Hepatitis B

Most of the recommendations are widely applicable. However, few data exist regarding community-based interventions to increase hepatitis B vaccination among health care workers. Although initiatives that effectively improve vaccination rates for other diseases may also be effective for hepatitis B, the effective and recommended health care–based interventions may not be applicable or may need considerable modification.

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