Immunization Strategies for Healthcare Practices and Providers
- Standards for Child, Adolescent, and Adult Immunization Practices
- The Guide to Community Preventive Services
- Health Care Practice Quality Improvement Programs
- Immunization Quality Improvement for Providers (IQIP)
- Immunization Information Systems (IISs)
- Essential Strategies for Health Care Provider Practices
- Selected References
Updated July 2020
Adam Bjork, Jennifer Hamborsky, Tom Shimabukuro
An important component of a vaccine provider’s practice is ensuring vaccines reach all patients who need them, when they need them. Providers should implement systems and programs to provide effective vaccine delivery and to maintain and increase vaccination coverage in their practices. By creating a culture of immunization in the practice, both providers and patients can vaccinate with confidence.
Vaccine-preventable disease rates in the United States are at low levels. In 2018, only four cases of rubella, one case of diphtheria, and 23 cases of tetanus were reported to CDC. However, the viruses and bacteria that cause vaccine-preventable diseases and death still exist. Diseases can be passed to unprotected persons or imported from other countries, as shown by the measles outbreaks that occurred in 2019. Diseases such as measles, mumps, and pertussis can be more severe than often assumed, and can result in social and economic costs in addition to the physical costs: sick children miss school, parents have to take time off from work, and outbreaks can severely disrupt health care systems.
Sustainable systems for vaccinating children, adolescents, and adults must be continued in the context of a changing health care environment. High vaccination coverage cannot be maintained with one-time or short-term efforts. Greater understanding of strategies to increase and sustain vaccination coverage is necessary to create lasting, effective immunization delivery systems.
Many public health strategies have been used to increase vaccination coverage. Some, such as school entry laws, have been effective in increasing vaccination compliance, but the effectiveness of other strategies (such as advertising) is not as well-documented. Some proven strategies (such as reducing costs, linking vaccination to Women, Infants, and Children (WIC) services, home visits) work well to increase coverage among specific populations, such as persons with limited access to immunization services. However, creating a culture of immunization within a health care practice also plays a critical role in maintaining and increasing vaccination coverage, as well as ensuring vaccines are delivered safely, effectively, and on time.
This chapter explores strategies health care providers can implement within their own practices. It covers system-level interventions such as quality improvement programs, as well as practice-level actions directed toward patients and provider staff.
All health care personnel in all settings are encouraged to ensure their patients are up to date on vaccinations. The National Vaccine Advisory Committee’s (NVAC) Standards for Child and Adolescent Immunization Practicesexternal icon and Standards for Adult Immunization Practice are recommended for use by all health care personnel in the public and private sectors. The standards represent the most desirable immunization practices that health care personnel should strive to achieve, regardless of whether they actually provide vaccinations. Providers implementing these standards will help ensure their patients are fully vaccinated, thereby helping to increase vaccination coverage and prevent outbreaks.
The Standards for Child and Adolescent Immunization Practices outline standards within five categories:
- Availability of vaccines
- Assessment of immunization status
- Effective communication about vaccine benefits and risks
- Proper storage and administration of vaccines and documentation of vaccinations
- Implementation of strategies to improve vaccination coverage
The Standards for Adult Immunization Practice include the following four standards:
- Assess immunization status of all adult patients at every clinical encounter.
- Strongly recommend vaccines that patients need.
- Administer vaccine or refer patients to a vaccine provider.
- Document vaccines received by patients.
The Guide to Community Preventive Services also known as the Community Guide, is a collection of evidence-based findings from the Community Preventive Services Task Force. The findings are based on a review of effectiveness data and economic evidence. The vaccination section of the Community Guide describes strong or sufficient evidence to support several provider-based immunization strategies discussed throughout this chapter. The task force’s full recommendations can be found at the Community Guide: Vaccinationexternal icon.
Immunization quality improvement projects can be particularly effective because vaccination is a dynamic, critical, and measurable area of health care. It is rapidly evolving, making fast strides in some areas, but lagging in others, such as human papillomavirus (HPV) vaccination.
CDC encourages health care personnel to consider implementing immunization quality improvement (QI) projects that:
- Generate measurable increases in child, adolescent, and adult vaccination coverage.
- Bring about measurable increases in HPV vaccination coverage, particularly rates of coadministration with other adolescent vaccines at the 11- to 12-year-old visit.
- Bring about measurable increases in vaccination coverage of pregnant women, specifically for influenza and pertussis.
- Reduce disparities in vaccination coverage, whether associated with race, ethnicity, type of health insurance including lack of insurance, or any other factor resulting in less than optimal coverage.
CDC has implemented the Immunization Quality Improvement for Providers (IQIP) program, which targets children and adolescents. Information about other immunization quality improvement programs can be found at Quality Improvement Projects Targeting Immunization.
CDC works with state, local, and territorial public health agencies to administer a QI program to introduce and sustain new or improved immunization practices. Designed to increase on-time vaccination at the provider level, IQIP strategies are intended to increase vaccine uptake among child and adolescent patients in adherence to the Advisory Committee on Immunization Practices (ACIP) recommended routine immunization schedule. IQIP is targeted toward quality improvement among providers enrolled in the Vaccines for Children (VFC) program.
IQIP serves to assist and support health care personnel by identifying opportunities to improve vaccine uptake, determining options for improving immunization delivery practices, and ensuring providers are:
- Aware of and knowledgeable about vaccination coverage within their practices and missed opportunities to vaccinate
- Motivated to try new immunization service delivery strategies and incorporate changes into their practices
- Capable of sustaining changes and improvements to their immunization delivery services
The IQIP Process
IQIP is a 12-month process where public health representatives and VFC providers collaborate to identify QI strategies to increase vaccine uptake by improving and enhancing immunization workflow. The collaborative process includes vaccination coverage measurement at or near the time of an initial site visit and again one year later to evaluate progress. Technical assistance and support occur at two- and six-month intervals to aid providers in staying on course with implementing strategies to improve vaccine uptake.
IQIP strategies include:
- Scheduling the next immunization visit before the patient leaves the provider site
- Leveraging immunization information system (IIS) functionality to improve immunization practice
- Giving a strong vaccine recommendation for patients
- Optional strategies as defined by the needs of state and local communities
Additional information on the IQIP process is also available at IQIP At-A-Glance.
IQIP has replaced CDC’s previous Assessment, Feedback, Incentives, and eXchange (AFIX) quality improvement program to better address the current health care environment.
Many record-keeping tasks, as well as patient reminder and recall processes, can be greatly simplified by participation in an immunization information system (IIS). An IIS is a confidential, population-based, electronic database that records all vaccine doses administered by participating providers to persons residing within a given jurisdiction. In some areas, an IIS links to a complete medical record. While electronic health records (EHRs) include vaccination information, they may not provide a consolidated immunization history. An IIS provides a single data source for all community vaccination providers, enabling them to access records of persons receiving vaccinations from multiple providers. Data exchange between IISs, EHRs, and other information systems helps ensure timely vaccinations and record consolidation and allows immunization personnel to work more efficiently.
- At the point of clinical care, an IIS can provide consolidated immunization histories for use by a provider in determining appropriate patient vaccinations.
- At the population level, an IIS provides aggregate data on vaccinations for use in surveillance and program operations and for guiding public health action, with the goals of improving vaccination coverage and reducing rates of vaccine-preventable diseases.
The Community Guide recommends IISs based on strong evidence that their use increases vaccination coverage. IISs can directly contribute to efforts to increase vaccination coverage through their abilities to:
- Create or support effective interventions such as patient reminder and recall systems, provider assessment and feedback, and provider reminders.
- Generate and evaluate public health responses to outbreaks of vaccine-preventable disease.
- Facilitate vaccine inventory management and accountability.
- Determine patient immunization status to inform decisions made by health care providers, clinicians, health departments, and schools.
- Aid surveillance and investigations of vaccination coverage, missed vaccination opportunities, and invalid dose administration.
Federal, state, and local public health agencies are continuing their efforts to improve IISs and to increase participation by vaccine providers. IISs are a key to increasing and maintaining vaccination coverage, and they offer advantages for providers, patients, and state and federal immunization program staff. More information about IISs is available at Getting Started with IIS and Basics of Immunization Information Systems (IISs)pdf icon.
In addition to implementing a quality improvement program such as IQIP and participating in an IIS, there are other effective practice strategies that complement these programs. These strategies focus on patient confidence in vaccination and provider development of a culture of immunization within a practice.
Strong Vaccination Recommendation
A strong recommendation by a health care provider is a powerful motivator for patients to comply with vaccination recommendations. A recommendation from a health care provider remains the number one reason parents decide to vaccinate. Even initially reluctant adults are likely to receive an influenza vaccination when the health care provider’s opinion of the vaccine is positive. Studies show a parent who receives a recommendation from their child’s health care provider is four to five times more likely to get the HPV vaccine for their child.
Research has also shown the way a recommendation is presented makes a difference. When providers use a presumptive approach (one that assumes parents will choose to vaccinate), parents are more likely to accept vaccines than when a participatory approach (one that presents parents with a decision to make) is used. A research study looking at health care personnel’s interactions with parents during vaccine visits showed parents were more likely to express concerns when providers used language asking parents about their vaccination plans. In this study, the presumptive approach resulted in significantly more parents accepting vaccines for their children, especially at first-time visits.
In practice, a provider using a presumptive approach might say, “Your child needs DTaP, Hib, and hepatitis B shots today.” A participatory approach might sound like, “Have you thought about the shots your child needs today?”
CDC’s #HowIRecommend video series features health care providers sharing how they recommend vaccines in their practices.
Take Time to Answer Questions
A strong recommendation will be enough to persuade many patients and parents to accept vaccines. However, some patients and parents might need more information or additional reassurance. An opportunity for questions should be provided before each vaccination. Discussion of the benefits and risks of vaccination is sound medical practice and providers are required by law to distribute vaccine information statements (VISs) before each dose of vaccine.
Data from CDC’s National Immunization Survey-Teen show when parents receive a recommendation for HPV vaccination from their child’s health care provider, about a quarter of parents still choose not to have their child vaccinated. These parents may have concerns that need to be addressed about the safety or effectiveness of the vaccine. Surveys of parents of young children have shown while most parents plan to vaccinate on schedule, many parents still have questions, often related to vaccine ingredients, vaccine safety in general, or side effects.
If a parent has concerns, resists following the recommended immunization schedule, or questions a provider’s strong recommendation, this doesn’t necessarily mean they won’t accept vaccines. Sometimes parents simply want to hear their provider’s answers to their questions. Providers should be prepared to answer parents’ questions succinctly and accurately, using terms parents understand. Effective, empathic vaccine risk communication is essential in responding to misinformation and concerns. It’s important to remind parents that state laws for school or child care entry might require unvaccinated children to stay home from school during outbreaks. For patients who question or refuse vaccination, identifying common ground and discussing measures for deferring vaccination are more effective public health strategies than excluding these patients from a practice.
Providers can also train their staff in how to address basic vaccine questions to help save time during vaccine discussions and ensure parents hear consistent messages about vaccines.
CDC, the American Academy of Pediatrics, the American Academy of Family Physicians, and other professional organizations have each developed resources to assist providers and parents in making decisions that are best for a child’s health. CDC resources may be found at Provider Resources for Vaccine Conversations with Parents.
Health care providers and their staff can also use CDC’s “Talking to Parents about Vaccinespdf icon” tip sheet to prepare for common questions parents have about vaccines.
For adults, providers can SHARE important information to help patients make informed decisions about vaccinations:
- Share the tailored reasons why the recommended vaccine is right for the patient based on his or her age, health status, lifestyle, occupation, or other risk factors.
- Highlight positive experiences with vaccines (personal or in the practice), as appropriate, to reinforce the benefits and strengthen confidence in vaccination.
- Address patient questions and concerns about the vaccine, including side effects, safety, and vaccine effectiveness in plain and understandable language.
- Remind patients that vaccines protect them and their loved ones from many common and serious diseases.
- Explain the potential costs of getting the disease, including serious health effects, time lost (missing work or family obligations), and financial costs.
When recommending influenza vaccine, it may also be helpful to explain that the vaccine can reduce the severity of illness among those who contract influenza.
Despite efforts by providers to adhere to appropriate immunization practices, there may be unknown obstacles to vaccination within the practice. Barriers to vaccination may be physical or psychological.
Physical barriers might include inconvienient clinic hours for working patients or parents, long waits at a clinic, or transportation issues. Providers are encouraged to determine the needs of their specific patient population and address obstacles to vaccination by taking appropriate actions, such as extending clinic hours or holding special vaccination events.
Psychological barriers to health care are often more subtle but may be just as important. Unpleasant experiences (e.g., fear of injections or difficulty leaving work for an appointment) may lead patients to postpone receiving needed vaccines. Concerns about vaccine safety contribute to some parents delaying or refusing recommended vaccines for their children. Overcoming such barriers calls for both knowledge and interpersonal skills on the part of the provider—knowledge of vaccines, recommendations, and reliable sources of accurate information to provide to patients and parents, as well as communication skills to address fears and misconceptions and provide a supportive and encouraging environment for patients. More information about provider resources is available at Provider Resources for Vaccine Conversations with Parents.
Another obstacle to vaccination is a missed opportunity at a health care encounter in which a person is eligible to receive a vaccine but is not vaccinated completely. Missed opportunities can occur in all settings in which vaccines are offered, whether routine or not.
Missed opportunities occur for several reasons. Many health care providers avoid simultaneous administration of multiple injectable vaccines, frequently citing concerns about reduced immune response, adverse events, or perceived parental objections. These concerns are not supported by scientific data. Providers might even be unaware a child or adult needs a vaccination. In addition, providers sometimes follow invalid contraindications (see Table 4-2 in ACIP’s General Best Practice Guidelines for Immunization for a list of conditions incorrectly perceived as contraindications or precautions).
Some reasons for missed opportunities relate to larger system issues, such as policies of only vaccinating children at well-care visits or not vaccinating siblings. Other reasons relate to institutional or bureaucratic regulations, such as state insurance laws denying reimbursement if a vaccine is administered during an acute-care visit.
Several studies have shown eliminating missed opportunities could increase vaccination coverage by up to 20%.
Providers should implement systems to ensure the practice never misses an opportunity to vaccinate. Establish a policy to vaccinate at every visit—not just well visits—and schedule the next vaccination appointment before the patient leaves.
Adult Vaccination Barriers
Recognized barriers to adult vaccination include:
- Limited access to health care
- Multiple competing priorities for providers who care for adult patients
- Low awareness among adults about recommended vaccines and their benefits
- Challenges in coordinating care for adults who often have more than one medical provider
- A complicated adult immunization schedule
- Vaccine cost and reimbursement
Professional societies such as the American College of Physicians and American College of Obstetricians and Gynecologists have developed programs to support providers in improving vaccination coverage among their patients. These organizations and the National Adult and Influenza Immunization Summitexternal icon offer educational resources, tools, and strategies to overcome challenges to vaccinating adults.
Creating a Culture of Immunization within a Practice
Creating a culture of immunization means including every member of the practice in vaccination efforts through:
- Consistent messaging about the importance of vaccines and about vaccine effectiveness and safety at all levels of the practice
- Adherence to proper vaccine storage, handling, and administration procedures
- Implementation of effective workflow processes to take advantage of every opportunity to vaccinate
Practices fostering support for vaccination:
- Save time.
Less time spent in vaccine conversations by involving practice staff in reinforcing vaccine recommendations and implementing effective workflow processes
- Save money.
Less money spent on lost vaccine by adhering to proper vaccine storage, handling, and administration practices
- Empower families.
Strengthened trust with families by helping patients and parents make informed decisions
It’s an immunization delivery best practice for every provider setting to designate an immunization coordinator. This individual should be the provider site’s point person for activities such as:
- Ensuring all vaccines are stored and handled correctly within the practice
- Helping to ensure all staff are trained in their role in immunization delivery and patient education
- Monitoring the practice’s vaccination coverage
- Ensuring all staff know how to address questions from patients and parents so there is consistent messaging about vaccines
- Promoting and motivating staff implementation of immunization quality improvement strategies to improve immunization workflow, delivery, and, ultimately, vaccine uptake
By being familiar with the practice’s vaccination coverage and understanding more about why some patients are not up to date with their vaccines, providers can implement interventions to increase coverage in their practice.
Vaccines for Children (VFC) Program
Cost can be a barrier to vaccination for many patients. In addition to evaluating the fee schedules for possible adjustments, providers should be knowledgeable about the VFC program, the state’s Children’s Health Insurance Program (CHIP), and other vaccine-focused programs available within their jurisdiction.
A provider should consider participating in the VFC program if the practice sees children and adolescents (18 years of age or younger) who meet one or more of the following criteria:
- American Indian or Alaska Native
- Underinsured (only eligible to receive vaccines in a federally qualified health center or rural health clinic)
Being a VFC provider reduces up-front costs because practices are provided vaccines for VFC-eligible children at no cost. Providers can charge an administrative fee to offset the cost of doing business. VFC-eligible patients benefit because they avoid having to go somewhere else to get the vaccines they need. State health departments can provide more information about becoming a VFC provider or visit Vaccines for Children (VFC) program.
Vaccination Reminders for Providers
Providers can create reminder systems to help them remember which vaccinations a patient needs. Examples of reminder systems are:
- A computer-generated list that notifies a provider which children being seen during the clinic session are past due on vaccinations
- A stamp with a message such as “no pneumococcal vaccine on record” that staff can put on the chart of a person age 65 years or older
- A “vaccination due” clip that staff attaches to the chart of an adolescent who has not had HPV vaccine
- An electronic reminder that appears when a provider accesses an electronic health record
Reminder systems vary according to the needs of the provider. In addition to raising vaccination coverage in the practice, systems serve to heighten staff awareness of the need to continuously check the vaccination status of their patients.
Standing orders are protocols whereby nonphysician medical personnel may vaccinate patients without direct physician involvement at the time of the vaccination. Standing orders are implemented in settings such as clinics, hospitals, and long-term care facilities. Standing orders have had positive effects on vaccination coverage among children and adults.
Standing order protocols should:
- Identify persons eligible for vaccination based on their age, their immunization status, or the presence of a medical condition putting them at high risk.
- Provide adequate information to patients or their guardians regarding the risks and benefits of a vaccine and document the delivery of that information.
- Record patient refusals or medical contraindications.
- Record administration of a vaccine(s) and any postvaccination adverse events, according to institution- or physician-approved protocol.
- Provide documentation of vaccine administration to patients and their primary care providers.
Standing order protocols should also specify that vaccines be administered by health care personnel trained in screening patients for contraindications to vaccination, administering vaccines correctly, and monitoring patients for adverse events in accordance with state and local regulations.
Anyone responsible for administering vaccines should be knowledgeable about immunization principles, scheduling, safety and effectiveness, and proper administration techniques. Starting with your front office, ensure each staff member is aware of the importance of vaccines, educated on proper immunization practices and recommendations, and prepared to answer patient questions as related to their position. Numerous educational materials in a variety of formats are available from CDC and some state, local, and territorial health departments, hospitals, and other professional organizations. CDC’s immunization-related education and training resources can be found at Immunization Education and Training.
Patient records are essential to a medical practice, and maintaining these records remains a critical part of providing optimal health care. Immunization records, in particular, must be accurate and meet all applicable legal requirements, as well as requirements of any specific program (such as the VFC program) in which the provider participates. These records should be available for compliance inspections and should be easy to interpret by anyone examining them.
Active medical records must reflect which patients are actually in the practice, and charts of persons who have moved or are obtaining services elsewhere should be clearly marked or removed. Records should be kept up to date as new vaccinations are administered, and all information regarding each vaccine and its administration should be complete.
Because patients often receive vaccines at more than one provider’s office, communication between sites is essential for maintaining complete and accurate vaccination records. School-based, public health, and community-based vaccination sites should communicate with primary care personnel through quick and reliable methods. IISs provide the most seamless and comprehensive avenue for sharing information; however e-mail, telephone, or fax can also be used. Using an IIS or other mechanism is increasingly important as more venues outside the medical home offer vaccinations.
- American Academy of Pediatrics, Committee on Community Health Services and Committee on Practice and Ambulatory Medicine. Increasing Immunization Coverage. Pediatrics 2003;112:993–996.
- CDC. Recommendations of the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics, and the American Academy of Family Physicians: Use of reminder and recall by vaccination providers to increase vaccination rates. MMWR 1998;47:715–717.
- Dietz VJ, Baughman AL, Dini EF, Stevenson JM, Pierce BK, Hersey JC. Vaccination practices, policies, and management factors associated with high vaccination coverage levels in Georgia public clinics. Arch Pediatr Adolesc Med 2000;154:184–189.
- Dini EF, Linkins RW, Sigafoos J. The impact of computer-generated messages on childhood immunization coverage. Am J Prev Med 2000;18(2):132–139.
- Lau M, Lin H, Flores Glenn. Factors associated with human papillomavirus vaccine-series initiation and healthcare provider recommendation in U.S. adolescent females: 2007 National Survey of Children’s Health. Vaccine 2012;30:3112–3118.
- Yitalo KR, Lee H, Mehta, NK. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the U.S. National Immunization Survey. Am J Public Health 2013;103(1):164–169.
- LeBaron CW, Mercer JT, Massoudi MS, Dini EF, Stevenson JM, Fischer WM, et al. Changes in clinic vaccination coverage after institution of measurement and feedback in 4 states and 2 cities. Arch Pediatr Adolesc Med 1999;153:879–886.
- Lieu T, Black S, Ray P. Computer-generated recall letters for underimmunized children: how cost-effective? Pediatr Infect Dis J 1997;16:28–33.
- Lieu T, Capra A, Makol J, Black S, Shinefield H. Effectiveness and cost-effectiveness of letters, automated telephone messages, or both for underimmunized children in a health maintenance organization [Abstract]. Pediatrics 1998;101:690–691.
- National Vaccine Advisory Committee. Standards for child and adolescent immunization practices.
- National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice. Public Health Reports 2014;129:115–123.
- Poland GA, Shefer AM, McCauley M, et al. Standards for adult immunization practices. Am J Prev Med 2003;25:144–150.
- Szilagyi PG, Rodewald LE, Humiston SG, et al. Immunization practices of pediatricians and family physicians in the United Statesexternal icon. Pediatrics 1994;94:517–23.
- Task Force on Community Preventive Services. Guide to Community Preventive Servicesexternal icon. Washington D.C.: HHS Online.
- Advisory Committee on Immunization Practices. Use of Standing Orders Programs to Increase Adult Vaccination Rates: Recommendations of the Advisory Committee on Immunization Practices. MMWR 2000; 49(RR01):15–26.
- Hill HA, Elam-Evans LD, Yankey D, Singleton JA, Dietz V. Vaccination Coverage Among Children Aged 19–35 Months—United States, 2015. MMWR 2016;65(39):1065–1071.
- Yawn BP, Edmonson L, Huber L, Poland GA, Jacobson RM, Jacobsen SJ. The impact of a simulated immunization registry on perceived childhood immunization status. Am J Managed Care 1998;4:186–192.