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Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents, and Adults

A Report on Recommendations from the Task Force on Community Preventive Services

Summary

The delivery and acceptance of recommended vaccinations is an ongoing challenge for health-care providers and health-care and public health systems, but specific interventions can increase levels of vaccination coverage. The Task Force on Community Preventive Services has conducted systematic reviews of 17 interventions designed to raise vaccination coverage levels in children, adolescents, and adults and made recommendations regarding the use of those interventions. This report provides a summary of the recommendations; informs readers of sources from which they can obtain the full review of the interventions and more detail regarding the application of the interventions at the local level; and informs readers regarding other work of the Task Force.

BACKGROUND

Despite the availability of safe and effective vaccines and substantial progress in reducing vaccine-preventable diseases, the delivery to and acceptance of vaccinations by targeted populations are essential to further reducing and eliminating vaccine-preventable causes of morbidity and mortality in the United States (1). The growing numbers of vaccines and complexity of vaccination schedules make delivering appropriate vaccinations in a timely manner increasingly difficult for health-care providers and health-care and public health systems (2). The recommendations included in this report are intended to guide communities in achieving or maintaining high levels of vaccination coverage and low rates of vaccine-preventable diseases.

INTRODUCTION

The independent, nonfederal Task Force on Community Preventive Services (the Task Force) is developing the Guide to Community Preventive Services (the Guide) with the support of the U.S. Department of Health and Human Services (DHHS) in collaboration with public and private partners. CDC provides staff support to the Task Force for development of the Guide, and CDC staff assisted in preparing this report. In addition, staff from CDC's National Immunization Program provided scientific leadership in conducting the reviews for the chapter "Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents, and Adults." However, the recommendations presented in the chapter and this report were developed by the Task Force and are not necessarily the recommendations of either CDC or DHHS.

The chapter on vaccine-preventable diseases is the first to be completed for the Guide. This report summarizes the recommendations from the Task Force, which are included in that chapter. This report also provides an overview of the process used by the Task Force to select and review evidence for the recommendations. A more complete description of the systematic reviews of effectiveness that are the foundation of the recommendations are in press (1). A full report of the recommendations and supporting evidence for the chapter will be published later in the American Journal of Preventive Medicine. That report will summarize the systematic reviews of effectiveness, the recommendations, and additional information (e.g., systematic reviews of economic evaluations, a discussion of barriers to implementation, and a summary of remaining research questions). This report and other chapter-related publications will provide guidance from the Task Force to personnel in state and local health departments and managed care organizations, purchasers of health care, those responsible for funding public health programs, and others who have interest in or responsibility for improving vaccination coverage in children, adolescents, and adults.

Methods

The Guide's methods for systematic reviews and linking evidence to recommendations will be described in detail elsewhere (1, American Journal of Preventive Medicine) but are described briefly in this report. In the Guide, evidence is summarized regarding a) the effectiveness of interventions; b) the applicability of effectiveness data (i.e., the extent to which available effectiveness data might apply to other populations and settings); c) other positive or negative effects of the intervention, including positive or negative health and nonhealth outcomes; d) economic consequences; and e) barriers to implementation of interventions (3). For each Guide chapter, multidisciplinary chapter development teams conduct reviews by

  • developing an approach to organizing, grouping, and selecting the interventions;
  • systematically searching for and retrieving evidence;
  • assessing the quality of and summarizing the strength of the body of evidence of effectiveness;
  • summarizing information regarding other evidence; and
  • identifying and summarizing research gaps.

For the chapter on vaccine-preventable diseases, the development team evaluated selected interventions to improve coverage levels for vaccinations universally recommended for certain age groups (Table 1). For example, measles, mumps, and rubella vaccinations are recommended for young children; hepatitis B vaccinations are recommended for adolescents; and annual influenza vaccinations are recommended for adults aged greater than or equal to 65 years. The team focused on interventions that are intended to improve routine delivery of those universally recommended vaccinations. They chose not to address vaccinations with more targeted indications (e.g., vaccinations recommended for persons with specific medical conditions such as asthma or vaccinations for travelers). The major outcomes that were considered included delivery of vaccinations and the occurence of vaccine-preventable diseases. Interventions reviewed were either single-component (i.e., using only one activity) or multicomponent (i.e., more than one related activity) to achieve desired outcomes.

The interventions included in the review were from a larger list and were prioritized for review by a multidisciplinary team of consultants,* which included some Task Force members. The selected interventions were chosen because they have an important impact or are widely practiced. The review evaluated 17 interventions, which were organized into three categories: a) increasing community demand for vaccinations, b) enhancing access to vaccination services, and c) provider-based interventions. Interventions were grouped together on the basis of their similarity and depth of available literature (i.e., the more literature available, the more subcategories that could be evaluated). Sometimes, the classification or nomenclature was different from that used in the original studies being reviewed. When such a discrepancy occurred, interventions were grouped according to the definitions stated in this report.

Some activities that might improve vaccination coverage were not considered interventions for the purposes of this review. Activities that provide information for public health action (e.g., immunization registries) provide useful information that might incorporate or lead to interventions (e.g., client reminder/recall, provider reminder/recall, and assessment and feedback for vaccination providers). However, registries were considered to be a part of the public health infrastructure rather than interventions. Similarly, improving vaccines (e.g., developing vaccines that are less likely to cause adverse reactions or increasing numbers of antigens contained in a vaccine, thus reducing the number of injections required) can lead to improvements in vaccination coverage. However, improved vaccines are made primarily for other reasons (e.g., harm reduction or to allow the administration of more antigens than would otherwise be feasible) and are, therefore, not considered to be interventions for the purposes of the chapter on vaccine-preventable diseases.

With rare exceptions (e.g., using 1998 papers for home visits and unpublished information regarding WIC** interventions), a study had to meet the following general criteria for inclusion in the reviews of effectiveness:

  • be published during 1980-1997;
  • address universally recommended childhood, adolescent, or adult 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 chapter development team's definition of one or more included interventions;
  • provide information on one or more predefined outcomes of interest; and
  • compare a group of persons who had been exposed to the intervention with a group who were not exposed or who were less exposed.

For each intervention reviewed, the team developed an analytic framework indicating possible links between the intervention under study and certain outcomes. The primary outcome of interest for determining effectiveness was a measure of vaccination (e.g., vaccination coverage levels or doses delivered) because the linkage between vaccination and reduction of disease, morbidity, and mortality is strong (4). Current low rates of certain vaccine-preventable diseases make using vaccination levels a more sensitive and feasible-to-measure indicator of intervention impact than using disease rates.

Each study meeting the inclusion criteria was read by two reviewers who used a standardized abstraction form to record

  • information regarding the intervention being studied;
  • the context in which the study was done (e.g., population or setting);
  • descriptions of the evaluation and results; and
  • an assessment of how well the study was executed.

The strength of the body of evidence of effectiveness was characterized as strong, sufficient, or insufficient on the basis of the number of available studies, the suitability of study designs for evaluating effectiveness, the quality of execution of the studies, the consistency of the results, and the effect size. Several studies need to show effects that were generally similar in size and direction for a body of evidence to be considered consistent. In addition, the overall strength of a body of evidence increases as numbers of studies increase, suitability of designs and quality of execution improve, and effect sizes increase.

The Guide links evidence to recommendations using an explicit process. In general, strength of evidence of effectiveness corresponds directly to strength of recommendations (e.g., strong evidence of effectiveness corresponds to an intervention being strongly recommended, and sufficient evidence corresponds to an intervention being recommended). Other types of evidence can also affect a recommendation. For example, evidence of important harms might result in an intervention not being recommended even if it is effective. Furthermore, a recommendation might be limited to a specific population (e.g., strongly recommended for adults but insufficient evidence for children) because evidence of effectiveness is applicable to some populations and settings but not others. A determination that evidence is insufficient is important for identifying areas of uncertainty but should not be confused with evidence of ineffectiveness. A determination of insufficient evidence assists in identifying a) areas of uncertainty regarding effectiveness of an intervention and b) specific continuing research needs. In contrast, evidence of ineffectiveness leads to a recommendation that the intervention not be used.

RESULTS

The systematic search by the chapter development team identified 197 studies that met the inclusion criteria (1). Of these, 79 were excluded from further consideration on the basis of limitations in their execution or design and were not considered further (1). Task Force recommendations were based on the remaining 118 qualifying studies (1),*** all of which had good or fair execution and the following designs:****

Greatest Suitability for Assessing Effectiveness

  • randomized trials, 33 studies;
  • nonrandomized trials, 24 studies;
  • group randomized trials, 14 studies;
  • other designs with concurrent comparison groups, 5 studies; and
  • prospective cohort, 3 studies;

Moderate Suitability for Assessing Effectiveness

  • time-series, 10 studies; and
  • retrospective cohort, 4 studies;

Least Suitability for Assessing Effectiveness

  • before/after, 16 studies; and
  • cross-sectional, 9 studies.

Considerable variation existed in the numbers of studies available per intervention. For example, client reminder/recall interventions and provider reminder/recall interventions had 42 and 29 qualifying studies, respectively, whereas community education-only programs, school-based vaccination programs, and vaccination interventions in child care centers had one or no qualifying studies for evaluation. This report summarizes the interventions, findings from the reviews, and the Task Force recommendations (Table 2).

USE OF THE RECOMMENDATIONS IN COMMUNITIES AND HEALTH-CARE SYSTEMS

These recommendations and the reviews on which they are based will be useful for choosing interventions, but local contextual information is also important. Local context includes observed problems, community preferences and priorities, and specific interventions that are feasible and appropriate. Choosing interventions that work in general and that are well-matched to local needs and capabilities, then implementing those interventions well, is vital for improving vaccination coverage at the local level.

A starting point for addressing vaccine-preventable disease problems in communities and health-care systems is to assess activities currently being performed, current levels of vaccination coverage, and information regarding vaccine-preventable disease rates. These should be compared with such relevant goals as those in Healthy People 2000 (5), Healthy People 2010 (U.S. Department of Health and Human Services, Draft for Public Comment, September 1998), and additional applicable goals developed locally. In addition to assessing overall progress towards vaccination goals, health planners should also consider whether special attention is warranted for population groups at high risk. In general, the lower the vaccination coverages and the higher the burden of vaccine-preventable diseases in a population or subgroup, the greater the need to improve coverage. For example, all vaccine-preventable diseases except tetanus are primarily spread by person-to-person contact among unvaccinated persons. Low vaccination coverage levels (6,7) and crowding can be particularly common among urban and low-socioeconomic populations. Therefore, improving coverage among persons living in poverty in urban communities should be a top priority.

When improvement in vaccination coverage is needed, the causes of underimmunization should be assessed and interventions chosen that address local problems. The chapter on vaccine-preventable diseases groups interventions into categories to enable users to match interventions to problems. For example,

  • Increasing Community Demand for Vaccinations -- If lack of knowledge among clients regarding need for vaccination contributes to low coverage, a strategy to increase demand can be useful.
  • Enhancing Access to Vaccination Services -- If an undervaccinated population has few or no contacts with the health-care system, an intervention to increase access can be appropriate.
  • Provider-Based Interventions -- In the United States, most persons accept the need for vaccinations and are seen periodically in health-care settings; unfortunately, providers often miss opportunities to vaccinate. Provider-based interventions can help address those missed opportunities.

Once a general strategy for addressing a local problem is selected, the recommendations in the chapter can be used in conjunction with local experience to help select appropriate interventions. Recommendations and effectiveness data can be used to assess the extent to which interventions have been found to consistently improve vaccination coverage. On the basis of those data, the use of strongly recommended and recommended interventions should be increased. Information regarding applicability can be used to assess the extent to which the interventions reviewed might match a particular local situation. Economic information, though limited, can be useful in identifying interventions that meet public health goals more efficiently than other available options for reaching the same goals. Reviews and recommendations provided in the Guide need to be considered along with such local information as resource availability, administrative structures, economic, social, and regulatory environment of organizations and practitioners. Guidance for implementation is available elsewhere (8).

ADDITIONAL INFORMATION REGARDING THE TASK FORCE AND THE GUIDE

During 1999-2000, Guide chapters will be prepared and released as each is completed. Other chapters of the Guide will cover such topics as motor vehicle occupant injury, tobacco use, sexual behavior, cancer, sociocultural environment, and oral health. Later, a compilation of the chapters will be published in book form. Additional information regarding the Task Force and the Guide is available on the Internet at <http://web.health.gov/communityguide>.

References

  1. Shefer AM, Briss PA, Rodewald L, et al. Improving immunization coverage rates: an evidence-based review of the literature. Epidemiol Rev 1999. (In Press)
  2. CDC. Achievements in public health, 1900-1999: impact of vaccines universally recommended for children-United States, 1990-1999. MMWR 1999;48:243-8.
  3. Pappaioanou M, Evans C. Development of the Guide to Community Preventive Services: a U.S. Public Health Service initiative. Journal of Public Health Management and Practice 1998;4(2):48-54.
  4. U.S. Preventive Services Task Force. Guide to clinical preventive services. 2nd ed. Alexandria, VA: International Medical Publishing, 1996.
  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: U.S. Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS) 91-50212.
  6. CDC. National, state, and urban area vaccination coverage levels among children aged 19-35 months--United States, July 1996-June 1997. MMWR;47:108-16.
  7. CDC. Vaccination coverage by race/ethnicity and poverty level among children aged 19-35 months--United States, 1996. MMWR 1997;46:963-8.
  8. CDC. Epidemiology and prevention of vaccine-preventable diseases. 5th ed. Atkinson W, Humiston S, Wolfe C, Nelson R, eds. Atlanta, GA: U.S. Department of Health and Human Services, CDC, National Immunization Program, January 1999.

* Consultants for the chapter on vaccine-preventable diseases included David Atkins, M.D., M.P.H., Agency for Health Care Policy and Research, Rockville, Maryland; Joseph Chin, M.D., M.S., Health Care Financing Administration, Baltimore, Maryland; Caswell A. Evans, D.D.S., M.P.H., National Institutes of Health, Bethesda, Maryland; Theresa W. Gyorkos, Ph.D., Montreal General Hospital and McGill University, Montreal, Quebec, Canada; George J. Isham, M.D., HealthPartners, Minneapolis, Minnesota; Susan M. Lett, M.D., M.P.H., Massachusetts Department of Public Health, Boston, Massachusetts; Rose Marie Matulionis, M.S.P.H., Association of State and Territorial Directors of Health Promotion and Public Health Education, Washington, DC; Lloyd F. Novick, M.D., M.P.H., Onondaga County Health Department, Syracuse, New York; Thomas N. Saari, M.D., University of Wisconsin, Madison, Wisconsin; William Schaffner, II, M.D., Vanderbilt University, Nashville, Tennessee; and Susan C. Scrimshaw, Ph.D., University of Illinois, Chicago, Illinois.

** The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is administered by the U.S. Department of Agriculture.

*** For additional information regarding the methods or results, contact

Peter A. Briss, M.D.
Division of Prevention Research and Analytic Methods
Centers for Disease Control and Prevention
1600 Clifton Rd., N.E., MS D-01
Atlanta, GA 30333
Phone: 404-639-4312
Fax: 404-639-4816
E-mail: pxb5@cdc.gov

**** A more detailed description of the methods for classifying study designs in the Guide will be published later in the American Journal of Preventive Medicine.



Table 1



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TABLE 1. Universally recommended vaccinations for children, adolescents, and adults
=============================================================================================
Population                   Vaccination                   Dosage
-------------------------------------------------------------------------------------------
All young children           Measles, mumps, and rubella   2 doses
                             Diphtheria-tetanus toxoid     5 doses
                               and pertussis vaccine
                             Poliomyelitis                 4 doses
                             Haemophilus influenzae        3-4 doses
                               type B
                             Hepatitis B                   3 doses
                             Rotavirus*                    3 doses before first birthday
                             Varicella                     1 dose

Previously unvaccinated or   Hepatitis B                   3 doses, total
  partially vaccinated
  adolescents
                             Varicella                     If no previous history of
                                                             varicella, 1 dose for children
                                                             aged <12 years, 2 doses for
                                                             children aged >=13 years
                             Measles, mumps, and rubella   2 doses, total
                             Tetanus-diphtheria toxoid     If not vaccinated during
                                                             previous 5 years, 1
                                                             combined booster during
                                                             ages 11-16 years

All adults                   Tetanus-diphtheria toxoid     1 dose administered every
                                                             10 years

All adults aged >=65 years   Influenza                     1 dose administered annually
                             Pneumococcal                  1 dose
-------------------------------------------------------------------------------------------
* Because rotavirus vaccine was not universally recommended during the period considered in
  this review, it is not reflected in these reviews.
=============================================================================================

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Table 2



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TABLE 2. Selected interventions to increase vaccination coverage among children, adolescents, and adults and recommendations
from the Task Force on Community Preventive Services regarding the use of these interventions
=====================================================================================================================================================================================
                                      Task Force
                                    recommendation
Intervention                           for use                      Intervention description                                 Key findings
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Increasing community demand for vaccinations
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Client reminder/ recall systems     Strongly recommended            Reminders that vaccinations are due (reminders)          Improves vaccination coverage in children and
                                                                    or late (recall) are provided to target populations.     adults in several settings and populations.

                                                                    Delivery techniques include telephone calls,             Effective when applied in individual practice
                                                                    letters, or postcards; contents of messages vary.        settings, across entire communities, and across
                                                                                                                             several intervention characteristics (e.g.,
                                                                    (Interventions that incorporate aspects of client        reminder or recall, content, theoretical basis,
                                                                    reminder/recall and home visits were classified          and method of delivery).
                                                                    under home visits.)
                                                                                                                             Effective whether used alone or as part of a
                                                                                                                             multicomponent intervention.

Multicomponent                      Strongly recommended            Target populations receive education regarding           Improves vaccination coverage among children
interventions that include                                          vaccinations.                                            and adults in both communitywide and
education                                                                                                                    clinic-based settings.
                                                                    Vaccination providers might also receive
                                                                    education.                                               Effective in several contexts.

                                                                    Used with at least one other activity to improve         (These interventions have incorporated
                                                                    vaccination rates.                                       education with other activities, including [from
                                                                                                                             most common to least common among the
                                                                                                                             qualifying studies] client reminders, provider
                                                                                                                             education, expanded hours or access, provider
                                                                                                                             reminders, reducing out-of-pocket costs,
                                                                                                                             client-held vaccination records, WIC
                                                                                                                             interventions, medical and psychosocial
                                                                                                                             assessments, nutrition services, and home visits.
                                                                                                                             Contribution of individual components to overall
                                                                                                                             effectiveness could not be attributed.)

Vaccination requirements            Recommended                     Laws or policies are enacted or enforced that            Effective in reducing vaccine-preventable
for child care, school,                                             require vaccinations or other documentation of           disease or improving vaccination coverage in all
and college attendance                                              immunity as a condition of attendance.                   relevant populations.

                                                                                                                             Differences in effectiveness of state laws based
                                                                                                                             on the law's specific characteristics or its
                                                                                                                             enforcement could not be determined.

Communitywide                       Insufficient evidence*          Provides information to a target population in a         The only qualifying study evaluated
education only                      (Small numbers of               geographic area.                                         effectiveness in changing vaccination delivery
                                    qualifying studies and                                                                   but had limitations in design and conduct and
                                    limitations in their            Can also provide information to vaccination              found inconsistent results in different
                                    designs and executions.)        providers.                                               subpopulations.

                                                                    Does not include other features (e.g.,                   No qualifying studies were identified that
                                                                    reminders), activities, or efforts limited to            evaluated effectiveness in changing knowledge
                                                                    specific settings.                                       and attitudes regarding vaccinations.

Clinic-based education              Insufficient evidence*          Provides information to persons served in a              No studies were identified that evaluated
only                                (Small numbers of               specific medical or public health clinical setting.      strategies other than printed educational
                                    qualifying studies and                                                                   materials.
                                    limitations in their            Does not include other features (e.g., reminders)
                                    designs and executions.)        or activities provided in other settings (e.g.,          The only qualifying study that evaluated
                                                                    school or child care centers).                           effectiveness of printed materials on vaccination
                                                                                                                             coverage found small and nonsignificant effects.

                                                                                                                             The two before/after studies that evaluated the
                                                                                                                             effects of vaccination information statements on
                                                                                                                             client knowledge or attitude towards vaccination
                                                                                                                             documented variable effects.

Client or family incentives         Insufficient evidence*          Provides financial or other incentives to                Three qualifying studies were identified, and
                                    (Small numbers of               motivate acceptance of vaccinations.                     those studies included four intervention arms.
                                    qualifying studies,
                                    variability in                  Incentives can involve either rewards or                 One intervention arm that evaluated use of
                                    interventions evaluated,        penalties.                                               incentives only found a not statistically
                                    and variability in size and                                                              significant (6%) net change in coverage.
                                    statistical significance of     (Some interventions with aspects of incentives
                                    results.)                       [e.g., WIC+ programs and vaccination                     The other three intervention arms evaluated
                                                                    requirements for child care, school, and college         incentives and reminders with and without
                                                                    attendance] are categorized elsewhere.)                  additional activities; those findings were variable
                                                                                                                             in size and statistical significance.

Client-held medical records         Insufficient evidence*          Provides to clients or family members medical            Four qualifying studies were identified, one of
                                    (Small numbers of               records that indicate which vaccinations have            which evaluated client-held records only and
                                    studies, limitations in         been received.                                           three of which evaluated client-held records
                                    study design and                                                                         used in combination with clinic-based education,
                                    conduct, variability in                                                                  client reminders, or multiple strategies.
                                    interventions evaluated,
                                    and variability in size and                                                              Effectiveness in improving vaccination coverage
                                    statistical significance of                                                              was variable in size and statistical significance.
                                    reported results.)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Enhancing access to vaccination services
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Reducing out-of-pocket              Strongly recommended            Can include providing free vaccinations or               Improves vaccination coverage in children and
costs                                                               administration, providing insurance coverage, or         adults across several settings and populations.
                                                                    reducing copayments for vaccinations at the
                                                                    point of service.                                        Effective when applied in individual clinical
                                                                                                                             settings, in statewide programs, or in national
                                                                                                                             efforts.

                                                                                                                             Effective whether used alone or as part of a
                                                                                                                             multicomponent intervention.

Expanding access in                 Strongly recommended            One or more of the following:                            As a part of multicomponent interventions,
medical or public health            as part of a                    Reduces the distance from the setting to the             improves vaccination coverage among children
clinical settings                   multicomponent                  population.                                              and adults in several contexts.
                                    intervention
                                                                    Increases or makes more convenient the hours             The contribution of individual components to
                                    Insufficient evidence*          during which vaccination services are provided.          the overall effectiveness of these interventions
                                    when used alone                                                                          cannot be attributed.
                                    (Small numbers of               Delivers vaccinations in clinical settings in which
                                    qualifying studies and          they were not provided previously                        Only two intervention arms evaluated expanded
                                    limitations in their            (e.g., inpatient units).                                 access only; effect sizes were small and
                                    designs and executions.)                                                                 statistical significance variable.
                                                                    Reduces administrative barriers to obtaining
                                                                    vaccination services within clinics (e.g.,
                                                                    "drop-in" clinics or an "express lane"
                                                                    vaccination service).

Vaccination programs in             Recommended                     Encourages the vaccination of low-income                 Improves vaccination coverage in children
Women, Infants, and                                                 clients of this nonmedical setting.                      whether used alone or as part of a
Children (WIC) settings+                                                                                                     multicomponent intervention.
                                                                    At a minimum, requires assessment of each
                                                                    child's immunization status and referral of              All qualifying studies evaluated assessing the
                                                                    underimmunized children to a health-care                 immunization status of WIC clients and either
                                                                    provider.                                                providing vaccinations on-site or referring
                                                                                                                             clients elsewhere for vaccination.
                                                                    Can include education, provision of
                                                                    vaccinations, and incentives to accept                   Some interventions also used monthly voucher
                                                                    vaccinations. (e.g., more frequent WIC* visits for       pick-up or provided free vaccinations.
                                                                    children who are not up-to-date with their               Contributions of individual components to the
                                                                    vaccinations).                                           overall effectiveness could not be determined.

Home visits                         Recommended                     Provides face-to-face services to clients in their       Improves vaccination coverage.
                                                                    homes.
                                                                                                                             Most available studies were conducted in
                                                                    Services can include education, assessment of            socioeconomically disadvantaged populations.
                                                                    need for vaccinations, referral for vaccinations,
                                                                    or provision of vaccinations.                            When applied only to improve vaccination
                                                                                                                             coverage, home visits can be highly
                                                                    Can also include telephone or mailed reminders.          resource-intensive relative to other available
                                                                                                                             options for improving vaccination coverage.

Vaccination programs                Insufficient evidence*          Intended to improve delivery of vaccinations to          Only one qualifying study was identified; it did
in schools                          (A single qualifying study      school attendees aged approximately 5-18 years.          not provide comparative data regarding
                                    and limitations in its                                                                   vaccination outcomes.
                                    design and execution.)          Usually includes vaccination-related education
                                                                    of students, parents, teachers, and other school
                                                                    staff and either provision of vaccinations or
                                                                    referral for vaccinations.

                                                                    Can also include incentives to participants and
                                                                    methods for acquiring written consent from
                                                                    parents.

                                                                    (Laws requiring vaccination for school entry are
                                                                    evaluated elsewhere.)

Vaccination programs in             Insufficient evidence*          Encourages the vaccination of children aged <5           Only one study was identified; it did not qualify
child care centers                  (No qualifying studies)         years.                                                   for the review.

                                                                    Requires assessment of each child's
                                                                    immunization status at entry into child care or at
                                                                    some point during the child's enrollment.

                                                                    Can also involve additional assessments at
                                                                    periodic intervals, education or notification of
                                                                    parents, referral of underimmunized children to
                                                                    a health-care provider, or provision of
                                                                    vaccinations on-site.

                                                                    (Laws requiring vaccination for child care
                                                                    centers are evaluated elsewhere.)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                    Provider-based interventions
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Provider reminder/recall            Strongly recommended            Informs those who administer vaccinations that           Improves vaccination coverage in adults,
                                                                    individual clients are due (reminder) or overdue         adolescents, and children whether used alone or
                                                                    (recall) for specific vaccinations.                      as part of a multicomponent intervention.

                                                                    Techniques by which reminders are delivered -            Effective across several intervention
                                                                    in client charts, by computer, by mail, or other -       characteristics (e.g., computerized or simple
                                                                    and content of the reminders vary.                       reminders, checklists, or flowcharts) and in
                                                                                                                             several settings and populations.
                                                                    (Interventions that incorporate elements of
                                                                    reminders and standing orders are classified as
                                                                    standing orders for the purposes of the chapter
                                                                    on vaccine-preventable diseases.)

Assessment and                      Strongly recommended            Involves retrospectively evaluating the                  Improves vaccination coverage in adults and
feedback for vaccination                                            performance of providers in delivering one or            children whether used alone or as part of a
providers                                                           more vaccinations to a client population and             multicomponent intervention.
                                                                    giving this information to the providers.
                                                                                                                             Effective across several settings and populations.
                                                                    Can also involve other activities (e.g., incentives
                                                                    or benchmarking: comparing performance to a              Specific characteristics (e.g., content, intensity,
                                                                    goal or standard).                                       use of incentives, or benchmarking) that
                                                                                                                             contribute most to effectiveness cannot be
                                                                                                                             determined from available data; however, a
                                                                                                                             variety of feedback interventions have been
                                                                                                                             consistently effective in several contexts.

Standing Orders                     Strongly recommended            Nonphysician medical personnel prescribe or              Improves vaccination coverage whether used
                                    for adults                      deliver vaccinations to client populations by            alone or as part of a multicomponent
                                    Insufficient evidence* for      protocol without direct physician involvement at         intervention and is effective in such settings as
                                    children                        the time of the interaction.                             hospitals, clinics, and nursing homes.
                                    (Small numbers of
                                    qualifying studies and          Settings include clinics, hospitals, and nursing         Insufficient evidence exists to assess the
                                    limitations in their            homes.                                                   effectiveness of standing orders in improving
                                    designs and executions.)                                                                 delivery of vaccinations to children because only
                                                                    (Dedicated vaccination clinics often operate             one qualifying study was available; that study
                                                                    under standing orders, but standing orders in            had limitations in design and conduct and
                                                                    that context were not considered to be an                reported effects not substantially different from
                                                                    intervention for the purposes of the chapter on          zero.
                                                                    vaccine-preventable diseases.)

Provider education only             Insufficient evidence*          Provides information to vaccination providers to         Only four qualifying studies were identified.
                                    (Small numbers of               increase their knowledge or change attitudes.
                                    qualifying studies,                                                                      Two studies of low-intensity interventions
                                    limitations in their design     Techniques can include written materials,                evaluated the impact of these interventions
                                    and conduct, and                videos, lectures, continuing medical education           regarding vaccination coverage; one
                                    variability in results.)        programs, and computerized software.                     documented small and nonsignificant impacts;
                                                                                                                             the other demonstrated that provider education
                                                                                                                             produced smaller impacts than provider
                                                                                                                             reminder/recall or standing orders.

                                                                                                                             Three studies of provider education-only
                                                                                                                             interventions documented variable impacts
                                                                                                                             regarding provider knowledge and attitudes.

                                                                                                                             The best-described and most-intensive
                                                                                                                             intervention produced improvements in provider
                                                                                                                             knowledge and attitudes.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* A determination that evidence is insufficient should not be confused with evidence of ineffectiveness. A determination of insufficient evidence assists in
  identifying (a) areas of uncertainty regarding effectiveness of an intervention and (b) specific continuing research needs. In contrast evidence of ineffectiveness
  leads to a recommendation that the intervention not be used.
+ The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is administered by the U.S. Department of Agriculture.
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