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Comprehensive Delivery of Adult Vaccination -- Minnesota, 1986-1992

Despite the availability of safe and effective vaccines, many adults still suffer from vaccine-preventable diseases. For example, each year an estimated 40,000-60,000 adults die as a result of pneumococcal infection and influenza (1). In addition, from 1985 through 1992, 433 (92.7%) of 467 cases of tetanus occurred among adults (CDC, unpublished data, 1993). Although up to 90% of influenza-related deaths occur among persons aged greater than or equal to 65 years, the 1991 National Health Interview Survey indicated that, during the preceding year, only 41% and 20% of persons aged greater than or equal to 65 years reported receiving influenza vaccine and pneumococcal vaccine, respectively (CDC, unpublished data, 1991). This report describes the efforts of the Hennepin County (Minneapolis) Community Health Department (HCCHD) (1990 population: 1.1 million) to provide comprehensive vaccination services to persons aged greater than or equal to 62 years.

Since 1979, HCCHD has conducted an annual influenza vaccination program in 14 clinics for persons aged greater than or equal to 62 years and for persons with high-risk conditions. From 1979 through 1992, the number of influenza vaccine doses delivered by the clinics increased from 1010 to 5649; 5% of the approximately 110,000 persons aged greater than or equal to 62 years in the county were vaccinated through these clinics in 1992. Because the prevalence of immunity to tetanus and diphtheria is low among persons aged greater than or equal to 65 years (2), in 1986 HCCHD initiated a plan for comprehensive vaccination services to older persons, including the provision of tetanus-diphtheria (Td) toxoids beginning in 1986 and pneumococcal vaccine beginning in 1991. Td toxoid doses were offered to all persons aged greater than or equal to 62 years who reported not having had received a booster within the preceding 10 years and to persons who were certain that they had not been vaccinated within at least 7 years. Pneumococcal vaccine was offered to all older persons who had never received this vaccine.

In 1986, of 3399 persons who received influenza vaccine, 707 (20.8%) received a Td toxoid. From 1986 through 1992, a total of 2489 older persons in the county received Td boosters. In 1991, of 4911 persons vaccinated against influenza, 993 (20.2%) also received pneumococcal vaccine. In 1992, of 5649 persons vaccinated against influenza, 720 (12.8%) received pneumococcal vaccine. An assessment for duplicate administration of pneumococcal vaccine in 1991 and 1992 indicated that of the 1713 doses administered at HCCHD clinics, only three (0.2%) were repeat doses; none of these persons reported adverse reactions to the vaccine.

To ensure efficient delivery of vaccines in the clinics, each type of vaccine (influenza, Td, and pneumococcal) was color-coded on all signs and U.S. Public Health Service Important Information Statements and Vaccine Information pamphlets, and color-coded posters were displayed for each type of vaccine listing the vaccine's indications and contraindications. In addition, nurses adhered to a protocol for informing patients about specific vaccinations.

To prevent repeat administration of pneumococcal vaccine, a three-part record keeping system was established: 1) all persons vaccinated against pneumococcal disease were given a Minnesota vaccination record card and asked to provide their primary health-care provider with this information; 2) a color-coded sticker was placed on the back of the patient's Medicare card as an additional record of vaccination; and 3) the names and dates of birth of all persons vaccinated were entered into a county public health department computer data base and made accessible at subsequent clinics. Reported by: JE Braun, MS, Minnesota Dept of Health; KL Nichol, MD, Veterans Administration Medical Center; J Monson, VM Thelen, Hennepin County Community Health Dept, Minneapolis. National Immunization Program, CDC.

Editorial Note

Editorial Note: Previous reports have identified at least three principal barriers to achievement of high vaccination levels among adults: 1) missed opportunities to vaccinate during contacts with health-care providers for unrelated reasons in offices, outpatient clinics, and hospitals (1); 2) lack of comprehensive vaccine-delivery systems in the public and private sectors (1); and 3) patient and provider fears concerning adverse events following vaccination (3). In contrast, receipt of vaccination against influenza has been positively associated with past history of vaccination, physician or nurse recommendations for influenza vaccination, and expressed intention to adhere to physician or nurse recommendations for influenza vaccination (3).

The findings in this report indicate that, from 1986 through 1992, by using a strategy of consistent reminders and providing comprehensive clinic-based vaccination services, HCCHD increased delivery of influenza and pneumococcal vaccines and Td toxoids among persons aged greater than or equal to 65 years. Simultaneous administration of vaccines, accelerated patient flow, and reduced confusion among older persons concerning the availability of the vaccines all appeared to contribute to this increase. The approach of HCCHD is consistent with the Standards for Adult Immunization Practice that encourages providers to administer simultaneously all vaccine doses for which a person is eligible at the time of each visit (4).

The program initiated by HCCHD and efforts by other public health departments to overcome barriers to adult vaccination (5,6) are practical examples of approaches necessary to achieve the national health objectives for the year 2000. These objectives include: 1) reducing epidemic-related pneumonia and influenza-related deaths among persons aged greater than or equal to 65 years (objective 20.2); 2) increasing to at least 60% pneumococcal and influenza vaccination levels among noninstitutionalized, high-risk populations (objective 20.11); and 3) increasing to at least 90% the proportion of public health departments that provide adult vaccinations (objective 20.16) (7). In 1991, of the 63 city and state health departments receiving federal vaccination grant funds to enable adult vaccination, 23 (36.5%) provided pneumococcal vaccine, 31 (49.2%) provided influenza vaccine, and 63 (100%) provided Td toxoids (CDC, unpublished data, 1992).

Increased vaccination coverage among adults and achievement of the national health objectives for vaccination will require multifaceted strategies, including publicly supported delivery mechanisms that reduce cost and accessibility constraints, collaboration between the public and private sectors to improve awareness of the national health objectives and vaccine delivery, and ongoing evaluation of current programs. The recent coverage of influenza vaccine by Medicare is an example of an attempt to remove a cost constraint and improve influenza vaccination levels among Medicare beneficiaries (8). National Adult Immunization Week (October 24-30, 1993) emphasizes the importance of appropriately vaccinating all adults and focuses attention on efforts that promote prevention and control of vaccine-preventable diseases. Additional information is available from the National Coalition for Adult Immunization, 4733 Bethesda Avenue, Suite 750, Bethesda, MD 20814; fax (301) 907-0878.


  1. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS, Hinman AR. Immunization policies and vaccine coverage among adults: the risk for missed opportunities. Ann Intern Med 1988;108:616-25.

  2. Crossley K, Irvine P, Warren JB, Lee BK, Mead K. Tetanus and diphtheria immunity in urban Minnesota adults. JAMA 1979;242:2298-

  3. Nichol KL, Lofgren RP, Gapinski J. Influenza vaccination: knowledge, attitudes, and behavior among high-risk outpatients. Arch Intern Med 1992;152:106-10.

  4. CDC. Public health burden of vaccine-preventable diseases among adults: standards for adult immunization practice. MMWR 1990;39:725-9.

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

  6. CDC. State and local influenza immunization program activities. MMWR 1988;37:705-7.

  7. 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; DHHS publication no. (PHS)91-50213:122-3.

  8. CDC. Final results: Medicare Influenza Vaccine Demonstration -- selected states, 1988-1992. MMWR 1993;42:601-4.

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