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National Coalition for Adult Immunization: Activities to Increase Influenza Vaccination Levels, 1989-1991

Older persons and persons with underlying health problems are at increased risk for complications of influenza infection; however, only 30% of persons aged greater than or equal to 65 years are vaccinated against influenza each year (1). This report describes initial efforts by the National Coalition for Adult Immunization's (NCAI) Influenza and Pneumonia Action Group (IPAG) to increase influenza vaccination of adults in the United States during 1990-1993, and highlights National Adult Immunization Week, October 25-31, 1992. Project Characteristics

In 1988, the NCAI was formed to increase the awareness of physicians, other health-care providers, and the general public about the need for and benefits of adult vaccination. In 1989, the NCAI convened the IPAG* to conduct disease-specific information and education activities. During 1990, the IPAG initiated a 3-year project in eight geographically and demographically diverse project areas to increase use of influenza and pneumococcal vaccines; another site was added in 1992.**

In each pilot site, partnerships were established between the local American Lung Association (ALA) and a state or local health department; these groups invited key community leaders from health-care provider and consumer groups to participate in establishing a community vaccination coalition. Coalition members were selected based on their efforts in promoting adult vaccination, particularly influenza and pneumococcal vaccination.

The primary objective of the IPAG is to increase influenza vaccine coverage as measured by vaccine distribution. Additional objectives are to 1) collect influenza vaccine delivery data from public health sites for at least 1 year before project start-up and for each project year, 2) increase the number of health-care providers who recommended and provided influenza vaccine to their patients each year, and 3) increase activities by the local ALA and community-leader coalitions aimed at improving health-care providers' awareness of the need for influenza vaccination.

Project activities included combinations of 1) physician presentations at county and state medical society meetings and hospital grand rounds; 2) feature articles on vaccination in health-care provider newsletters; 3) increased media attention to influenza vaccination (including newspaper articles, radio interviews, advertisements in weekly newspapers, bus-advertising placards, milk-carton and grocery-bag art, and billboards); 4) distribution of approximately 100,000 physician newsletters and an estimated 400,000 vaccination pamphlets, posters, and promotional buttons and stickers encouraging influenza vaccination; and 5) distribution and completion of adult-vaccination cards.

Site-specific data on influenza vaccine distribution were provided by the four U.S. influenza vaccine manufacturers, and for six of nine sites, the number of doses of influenza vaccine distributed by local public health clinics were provided by the state or local health departments. Program activities continue in the nine pilot sites, and additional ALA and health department partners have formed in other areas in the United States. Project Results

During the 1989-90 influenza season, influenza vaccination increased in each project site, compared with 1988-89 levels. In the first year of the project (i.e., the 1990-91 influenza season), distribution of vaccine doses increased from 2.3% to 23.9% in five of the eight sites compared with 1989-90 levels -- Minnesota (23.9%), South Dakota (11.0%), Washington (10.4%), Mississippi (5.9%), and Delaware (2.3%). Although declines occurred in three sites (New York City [-17.7%]; Lee County, Florida [-6.9%]; and Oklahoma [-6.3%]), distribution in these sites remained above levels in 1988-89. In addition, in two of these sites, vaccine distribution increased in public health clinics (Lee County [15.0%] and Oklahoma [14.6%]). Increases (from 4.5% to 22.3%) in public clinic vaccine distribution also occurred in the six sites reporting data on health department (i.e., public) clinic vaccine distribution. The largest increase (23.9%) in overall public and private vaccine distribution was reported by Minnesota.

Reported by: M Murphy, SR Mostow, MD, American Lung Association of Colorado; J Conner, Colorado Dept of Health. B Yoncha, American Lung Association of Delaware, Wilmington; MA Hoyt, Bur of Health Promotion and Disease Prevention, Div of Public Health, Delaware Dept of Health and Social Svcs. S Welch, Gulf Coast Lung Association, St. Petersburg; M Allison, District 8, Florida Dept of Health and Rehabilitative Svcs. D Berg, American Lung Association of Minnesota, St. Paul; D Peterson, Minnesota Dept of Health. JM Allred, Jr, Mississippi Lung Association; P McKee, V Mays, Mississippi State Dept of Health. FL Ruben, MD, M Harris, American Lung Association (Headquarters); C Bordes, American Lung Association of Queens, Forest Hills; O Theus, New York Lung Association; AM Costello, S Friedman, MD, Div of Immunizable Diseases, New York City Health Dept. J Rogers, American Lung Association of Oklahoma; R Toth, Immunization Program, Oklahoma State Dept of Health. K Wiebers, South Dakota Lung Association, Sioux Falls; W Gallo, Communicable Disease Program, South Dakota State Dept of Health. S McAlexander, American Lung Association of Washington, Seattle; M Borges, Adult Immunization Section, Washington Dept of Health. Influenza Br, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases; Div of Immunization, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Although vaccination programs have markedly reduced the incidence of vaccine-preventable diseases among children, vaccination programs for adults have been difficult to implement for at least four reasons: 1) comprehensive adult vaccine-delivery systems are not available in the public and private sectors; 2) although statutory requirements exist for vaccination of children, few such requirements exist for adults; 3) reimbursement mechanisms and coverage by third-party payors are limited in the public and private sectors; and 4) vaccination programs have not been established in most settings where adults congregate (e.g., the workplace and retirement communities).

Despite these barriers, strategies have been developed that are effective in enhancing influenza vaccination rates and reducing influenza-related morbidity and the associated need for health services (2-6). Most recently, the Medicare Influenza Vaccine Demonstration increased overall influenza vaccine coverage in 10 demonstration sites from an estimated baseline of 43% in 1988-89 to approximately 62% in 1991-92 (7) (Health Care Financing Administration, unpublished data, 1992). In addition, the California influenza vaccination program has documented steady increases in influenza vaccine delivery and in overall coverage (8) (Immunization Unit, California State Department of Health Services, unpublished data, 1992).

The findings in this report suggest that the collaboration of public and private organizations in the eight pilot sites was successful in raising total influenza vaccine doses distributed in five of the sites. Furthermore, doses distributed through public clinics increased for all sites that reported data, despite a drop in overall vaccine distribution in two of these sites, suggesting that a decrease in vaccine distribution occurred in private settings. However, other outreach public programs have stimulated vaccine delivery in private settings (7,9).

Efforts during the third year of the vaccination projects (i.e., the 1992-93 influenza season) will focus on strengthening influenza vaccination efforts and expanding to include pneumococcal vaccination activities. Health-care provider and patient-education materials about pneumococcal pneumonia will be distributed through local ALA offices. In addition, influenza and pneumococcal vaccine distribution during both the second and third years of the project will be assessed to measure the sustainability of the increases in vaccine coverage.

The national health objectives for the year 2000 include increasing to 60% the proportion of older and chronically ill noninstitutionalized persons who are vaccinated against pneumococcal and influenza infections (objective 20.11) (10). Attainment of this objective will require multifaceted strategies involving collaboration of public and private organizations to improve awareness regarding vaccine delivery and develop publicly supported delivery mechanisms that remove cost and accessibility constraints. National Adult Immunization Awareness Week draws attention to efforts that promote prevention and control of vaccine-preventable diseases among adults. Additional information is available from NCAI; telephone (301) 656-0003.


  1. Rodgers DV, Strikas RA, Martinez B, et al. Influenza vaccination among adults: results of the 1989 National Health Interview Survey [Abstract]. In: Program and abstracts of the CDC Epidemic Intelligence Service 41st annual conference. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992:33-

  2. Buffington J, Bell K, LaForce FM, et al. A target-based model for increasing influenza immunizations in private practice. J Gen Intern Med 1991;6:204-9.

  3. Fedson DS. Influenza prevention and control; past practices and future prospects. Am J Med 1987;82(suppl 6A):42-7.

  4. Barton MB, Schoenbaum SC. Improving influenza vaccination performance in an HMO setting: the use of computer-generated reminders and peer comparison feedback. Am J Public Health 1990;80:534-6.

  5. Nichol KL, Korn JE, Margolis KL, Poland GA, Petzel RA, Lofgren RP. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med 1990;89:156-60.

  6. Riddiough MA, Sisk JE, Bell JC. Influenza vaccination: cost-effectiveness and public policy. JAMA 1983;249:3189-95.

  7. CDC. Medicare Influenza Vaccine Demonstration -- selected states, 1988-1992. MMWR 1992;41:152-5.

  8. CDC. Successful strategies in adult immunization. MMWR 1991;40:700-3,709.

  9. CDC. National Adult Immunization Awareness Week. MMWR 1989;38:708-10.

  10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991:122; DHHS publication no. (PHS)91-50213.

    • Members of the NCAI's IPAG include the American Lung Association, the American College of Physicians, the Association of State and Territorial Health Officials, the American Health Care Association, the American Association of Retired Persons, the American Association of Homes for the Aging, the American Academy of Family Physicians, the United States Conference of Local Health Officers, the American Society of Hospital Pharmacists, the Canadian Lung Association, and CDC. ** The eight sites included the entire states of Delaware, Minnesota, Mississippi, Oklahoma, South Dakota, and Washington, and New York City and Lee County, Florida. Colorado was added in 1992.

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