Increase Immunization Rates Research Articles

Social Marketing as a Strategy to Increase Immunization Rates

Today in the United States, outbreaks of vaccine-preventable disease are often traced to susceptible children whose parents have claimed an exemption from school or child care immunization regulations. The origins of this immunization hesitancy and resistance have roots in the decline of the threat of vaccine-preventable disease coupled with an increase in concerns about the adverse effects of vaccines, the emergence of mass media and the Internet, and the intrinsic limitations of modern medicine. Appeals to emotion have drowned out thoughtful discussion in public forums, and overall, public trust in immunizations has declined. We present an often overlooked behavior change strategy-social marketing-as a way to improve immunization rates by addressing the important roots of immunization hesitancy and effectively engaging emotions. As an example, we provide a synopsis of a social marketing campaign that is currently in development in Washington state and that is aimed at increasing timely immunizations in children from birth to age 24 months.

Who has a clue to preventing the flu? Unravelling supply and demand effects on the take-up of influenza vaccinations

Influenza is a serious disease, especially for older people, and incomplete vaccination take-up poses a major public health challenge. On both the side of physicians and patients, there could be promising channels for increasing immunization rates, but no attempt has yet been made to empirically unravel their respective influences. Using exclusion restrictions implied by an economic model of physician–patient interactions, our study quantifies the particular effects of supply and demand on influenza immunization. On the supply side, our estimates highlight the importance of physician agency and physician quality, while a patient’s education and health behaviors are key demand side factors.

Estimates of measles case fatality ratios: a comprehensive review of community-based studies

Global deaths from measles have decreased notably in past decades, due to both increases in immunization rates and decreases in measles case fatality ratios (CFRs). While some aspects of the reduction in measles mortality can be monitored through increases in immunization coverage, estimating the level of measles deaths (in absolute terms) is problematic, particularly since incidence-based methods of estimation rely on accurate measures of measles CFRs. These ratios vary widely by geographic and epidemiologic context and even within the same community from year-to-year. To understand better the variations in CFRs, we reviewed community-based studies published between 1980 and 2008 reporting age-specific measles CFRs. The results of the search consistently document that measles CFRs are highest in unvaccinated children under age 5 years; in outbreaks; the lowest CFRs occur in vaccinated children regardless of setting. The broad range of case and death definitions, study populations and geography highlight the complexities in extrapolating results for global public health planning. Values for measles CFRs remain imprecise, resulting in continued uncertainty about the actual toll measles exacts.

The Impact of Changing Medicaid Enrollments on New Mexico's Immunization Program

BackgroundImmunizations are an important component to pediatric primary care. New Mexico is a relatively poor and rural state which has sometimes struggled to achieve and maintain its childhood immunization rates. We evaluated New Mexico's immunization rates between 1996 and 2006. Specifically, we examined the increase in immunization rates between 2002 and 2004, and how this increase may have been associated with Medicaid enrollment levels, as opposed to changes in government policies concerning immunization practices.Methods and FindingsThis study examines trends in childhood immunization coverage rates relative to Medicaid enrollment among those receiving Temporary Assistance for Needy Families (TANF) in New Mexico. Information on health policy changes and immunization coverage was obtained from state governmental sources and the National Immunization Survey. We found statistically significant correlations varying from 0.86 to 0.93 between immunization rates and Medicaid enrollment.ConclusionsNew Mexico's improvement and subsequent deterioration in immunization rates corresponded with changing Medicaid coverage, rather than the state's efforts to change immunization practices. Maintaining high Medicaid enrollment levels may be important for achieving high childhood immunization levels.

A comparison of populations vaccinated in a public service and in a private hospital setting in the same area

BackgroundImproving immunisation rates in risk groups is one of the main objectives in vaccination strategies. However, achieving high vaccination rates in children with chronic conditions is difficult. Different types of vaccine providers may differently attract high risk children.AimTo describe the characteristics of two populations of children who attended a private and a public immunisation provider in the same area. Secondarily, to determine if prevalence of patients with underlying diseases by type of provider differs and to study if the choice of different providers influences timeliness in immunisation.MethodsWe performed a cross-sectional study on parents of children 2 – 36 months of age who attended a private hospital immunisation service or a public immunisation office serving the same metropolitan area of Rome, Italy. Data on personal characteristics and immunisation history were collected through a face to face interview with parents of vaccinees, and compared by type of provider. Prevalence of underlying conditions was compared in the two populations. Timeliness in immunisation and its determinants were analysed through a logistic regression model.ResultsA total of 202 parents of children 2–36 months of age were interviewed; 104 were in the public office, and 98 in the hospital practice. Children immunised in the hospital were more frequently firstborn female children, breast fed for a longer period, with a lower birthweight, and more frequently with a previous hospitalisation. The prevalence of high risk children immunised in the hospital was 9.2 vs 0% in the public service (P = 0.001). Immunisation delay for due vaccines was higher in the hospital practice than in the public service (DTP, polio, HBV, and Hib: 39.8% vs 22.1%; P = 0.005). Anyway multivariate analyses did not reveal differences in timeliness between the public and private hospital settings.ConclusionChildren with underlying diseases or a low birthweight were more frequently immunised in the hospital. This finding suggests that offering immunisations in a hospital setting may facilitate vaccination uptake in high risk groups. An integration between public and hospital practices and an effort to improve communication on vaccines to parents, may significantly increase immunisation rates in high risk groups and in the general population, and prevent immunisation delays.

Barriers to Adult Immunization

Our aim was to provide a better understanding of why many adults fail to receive recommended immunizations. Consumers (N = 2,002) and healthcare providers (N = 200) completed structured telephone interviews concerning their attitudes and knowledge about adult vaccines and factors affecting their vaccination decisions. Self-reported immunization rates for tetanus, influenza, and pneumococcal vaccines (which were emphasized in the surveys) were lower than goal rates set by national guidelines. Among the most common reasons consumers gave for not receiving immunizations were lack of physician recommendations and mistaken assumptions (e.g., healthy people do not need immunizations). Healthcare providers tended to cite concerns such as side effects, fear of needles, and lack of insurance coverage as reasons consumers forego vaccination. Providers also cited practice issues, such as lack of an effective reminder system, as barriers to increasing adult immunization rates. We conclude that a better understanding of why adults do not get vaccinated is important for efforts to increase immunization rates in this broad age group.

Vaccination programs between individual autonomy and common welfare

Vaccinations are among the most effective and cost-effective means to prevent serious infectious diseases. Actual vaccination rates, however, still fall short of their full potential to reduce morbidity and mortality both in industrialized and low-income countries. Therefore, strategies to increase immunization rates are ethically and economically mandated, raising the following ethical issue: To what extent is it ethically appropriate to restrict individual autonomy by compulsory immunization requirements in order to achieve a sufficient collective protection of the community? Restrictions of individual autonomy are ethically justified if the following five conditions are met: (1) proven benefit, (2) favourable benefit-risk-ratio, (3) acceptable cost-benefit ratio, (4) as little restrictions as possible and (5) fair and transparent decision procedures. Depending on how far these five criteria are met, different strengths of recommendation result for each specific immunization program. However, there are good ethical and pragmatic arguments against compulsory vaccination enforced by law. Rather, one should try to strengthen public support and trust in vaccination programs by a proactive and persuasive information policy.

Who Has a Clue to Preventing the Flu? Unravelling Supply and Demand Effects on the Take-Up of Influenza Vaccinations

Influenza is a serious disease, especially for older people, and incomplete vaccination take-up poses a major public health challenge. On both the side of physicians and patients, there could be promising channels for increasing immunization rates, but no attempt has yet been made to empirically unravel their respective influences. Using exclusion restrictions implied by an economic model of physician-patient interactions, our study quantifies the particular effects of supply and demand on influenza immunization. On the supply side, our estimates highlight the importance of physician agency and physician quality, while a patient’s education and health behaviors are key demand side factors.

Managed Care Organizations’ Performance in Delivery of Adolescent Immunizations, HEDIS®, 1999–2002

Purpose The Health Plan Employer Data Information Set (HEDIS®) provides comparative information across health plans to measure the quality of care and preventive services for health plan beneficiaries. We examined recent trends in adolescent immunizations recommended by the Advisory Committee for Immunization Practices (ACIP) measured through HEDIS and reported to the National Committee for Quality Assurance (NCQA). Methods The study was based on a longitudinal regression analysis of commercial managed care organizations’ HEDIS measures from 1999–2002. HEDIS performance measures and plan characteristics include a sample of approximately 100–400 enrollees per plan each year. The outcome measures were the proportions of enrollees aged 13 years sampled in the plan who received measles–mumps–rubella vaccine (MMR), hepatitis B vaccine, and varicella vaccine. Results The immunization rates for all three antigens increased significantly from 1999 to 2002 (MMR: 57–68%; hepatitis B: 28–51%; and varicella: 21–38%). Factors in the final multivariable models that were found to be significantly associated with increased proportions immunized with MMR vaccine, hepatitis B vaccine, and varicella vaccine include year of report, presence of school entry laws, years in business up to 25 years, and operating in the northeastern U.S. region; the only factor associated with decreasing immunization rates for all antigens was the number of providers per 100 commercial enrollees. Conclusions Consistent with previous reports, adolescent immunization rates are improving yet remain suboptimal. Strategies to increase immunization rates, as well as to improve documentation of immunization status, among commercial health insurance plans need to be developed and implemented.

Reminder Cards and Immunization Rates Among Latinos and the Rural Poor in Northeast Colorado

Immunization rates are static in the United States. Risk factors for not being up to date (UTD) include ethnicity and lower socioeconomic status. Reminder cards increase immunization rates in urban settings. Their effect in poor, Latino, and rural children is unknown. Language-appropriate reminder cards were sent to active patients not UTD listing the vaccines missing; the card served as the physician order for the vaccine. Missed opportunities were addressed through discussion with staff and posters in patient care rooms. UTD rates before and after intervention were measured. Dual-purpose reminder/order cards increased the rate of UTD from 61.3% to 73.4%; children living near the clinic, patients who speak only Spanish, and Latinos overall showed preferential effectiveness. Children eligible to participate in the Vaccines for Children program had similar increases in UTD rates but had lower baseline and final UTD rates than did children not eligible for the Vaccines for Children program. The rate of missed opportunities did not change. The number of children to whom reminder cards needed to be sent for them to become fully immunized is 8 (number needed to treat). In poor, rural, and Latino populations, language-appropriate reminder/order cards increase immunization rates.

Disagreement on Immunization Recommendations: An Analysis of Lay-Clinician Interaction

Although the health benefits of vaccines have been well established, immunization rates among adults at risk for complications of viral and bacterial infections falls far short of federal recommendations. Various factors have been attributed to this problem. In this paper we consider an understudied factor, that of clinician-lay interactions on and disagreements over immunizations. We draw on data collected as part of a larger study of vaccine uptake among chronically ill adults. Qualitative methods were used to analyze transcripts of audio recordings of lay-clinician interactions made during health visits of patients eligible for influenza and or pneumococcal pneumonia vaccines. Our analysis revealed that lay expressions of discord over immunization recommendations centered on vaccine delivery, health beliefs, and personal experiences. Strategies used to quell disagreements included posing questions, providing information, and giving advice. Impediments to bringing about agreement over vaccines involved organizational policies and lack of clinician engagement with patient resistance. Settled disagreements resulted in immunization delivery; patients were not immunized under conditions of unresolved disagreement. We suggest that clinicians may wish to remain alert to sources of disagreement and seek to resolve discord in the service of increasing immunization rates and preventing illness in high-risk adults.

Assessment of an immunization program in a supermarket chain pharmacy

Vaccination is considered 1 of the 10 greatest public achievements in the last century. 1. Centers for Disease Control and Prevention. Ten great public health achievements: United States, 1900-1999. MMWR Morb Mortal Wkly Rep. 1999; 48: 241-243 PubMed Google Scholar Unfortunately, the Centers for Disease Control and Prevention (CDC) estimates that only 20% to 60% of at-risk adults receive immunizations for vaccine-preventable diseases. As health care providers, pharmacists are doing their part to increase immunization rates. Pharmacists were acknowledged in 2001 by Walter A. Orenstein, MD, then Director of the National Immunization Program, as “having the ability to help shape the success of our country's immunization initiatives.” Pharmacists also were recognized for their ability to “collaborate with others in the community to reach the most susceptible patients.” 2. Centers for Disease Control and Prevention. Department of Human Health and Services. Dear pharmacist letter. July 10, 2001; Google Scholar

Computer‐based multivariate economic analysis of neonatal‐intensive‐care‐unit‐based influenza vaccine administration to parents in a low‐socio‐economic, urban setting

Trivalent inactivated influenza vaccine has been shown to reduce the number of influenza-related outpatient visits and hospitalizations of children up to 24 months of age. The American Academy of Pediatrics, Centers for Disease Control, and Advisory Committee on Immunization Practices recommend that the influenza vaccine be administered to the first-person contacts of infants less than 6 months of age. However, the economic implications of increasing immunization rates by using the neonatal intensive care unit (NICU) as an arena to capture the parents of these infants has not been fully evaluated. We sought to examine the direct and indirect costs of a program to administer the influenza vaccine to parents in the NICUs of a cohort of tertiary-care units primarily serving a low socioeconomic population. The probabilities of infants being hospitalized because of infection from contact and of the efficacy of prophylaxis used in the present study were based on published results where possible, with an estimated 10% reduction in hospitalization of patients whose parents had received the vaccine. Variables in the 3- and 4-tiered analyses included chronic lung disease status, estimation if patients had siblings, vaccination status of siblings, seroconversion rate of vaccine, and parental vaccination status. Two thousand six hundred and thirty-two patients were analyzed using 2003 admission data from the New York City Regional Perinatal Center, which encompasses 11 level III NICUs. Hospitalization costs, indirect costs, and outpatient costs were assessed using previously published standard calculations. On the basis of this computer model, costs were $188 per patient per influenza season, including $6.80 per patient in outpatient costs. Administration of an NICU-based influenza vaccine increased costs to $200 per patient per influenza season, but decreased outpatient costs to $1.40 per patient. For cost savings to equal costs of vaccine administration, there must be either a 20% reduction in influenza hospitalizations of NICU patients or an increase in the sample size per influenza season to 4000 patients. The cost of administration of the influenza vaccine to parents of NICU patients is higher than the financial burden of influenza in this population as long as the sibling immunization rate remains low. Cost savings do not occur until the treated cohort increases to 4000 patients or the incidence of lung disease in this population increases. Further studies are needed to validate the cost savings of this mode and more accurately assess the financial savings.

Improving Pediatric Immunization Rates in a Safety-Net Delivery System

Denver Community Health Services (DCHS)' goal was to increase childhood immunization rates in the high-risk pediatric patient population served through its safety-net delivery system. The specific goal of the initiative was to ensure that children younger than 3 years of age with at least one primary care visit received all recommended vaccines by 24 months of age. An immunization registry was developed to accurately track patients, regular assessment of immunization levels were conducted with provision of clinic-specific feedback, and team-based quality improvement meetings were held. The computerized immunization registry assisted in implementing all the remaining improvement activities. For example, improvement of on-time delivery of vaccines in primary care clinics was accomplished through a rules engine in the vaccine registry, standing orders for vaccine delivery, and implementation of vaccine delivery protocols that eliminated missed opportunities. From 1995 to 2006, Denver Community Health documented a 47% increase in immunization rates for 2-year-old patients and a 26% increase for 1-year-old-patients. Two-year-old immunization rates exceeded 85% by the end of this time period. The initiative improved pediatric immunization rates with demonstrated sustainability during a 10-year period. Success is attributed to staff commitment to process improvement activities and use of a patient registry for pediatric immunization delivery.

THIS ISSUE: Maximizing Office-based Immunization

Vaccines are a great public health achievement only if we can deliver those vaccines to individual patients. It is impressive that gradually increasing immunization rates are so consistent in spite of a new birth cohort every year, complexity of the schedule, shortages, changes in reimbursement policies, and vaccine news stories. Pediatricians have always embraced their public health role, especially as immunization providers. By helping practices improve their immunization delivery system, rates can be raised throughout a community by first maximizing office-based immunization.

Strategies for improving pneumococcal vaccination in eligible patients

Despite the fact that invasive Streptococcus pneumoniae remains a leading cause of death, current levels of immunization in the at risk population remain low and well below the 90% goal for Healthy People 2010. A number of intervention strategies to increase immunization rates (for influenza and pneumonia) have been demonstrated to be effective in increasing these rates when used alone or in combination. A summary of this literature is presented including recent data on the effectiveness of pay-for-performance approaches for increasing preventive care. Data are also presented on intervention strategies judged to be most effective in a large health care system, the Veterans Health Administration, which has essentially reached the Healthy People 2010 goal for pneumococcal immunization.

Focus on the Myths: An Approach To Improving Healthcare Worker Influenza Immunization Rates

ISSUE: Every year approximately 200,000 Americans are hospitalized and more than 36,000 die from influenza and influenza-related complications, and influenza is the sixth leading cause of death in the United States; despite longstanding recommendations for healthcare worker immunization from the Centers for Disease Prevention and Control, immunization rates for health care workers average only about 36%. For this pediatric care organization which includes inpatient and outpatient rehabilitative and habilitative services, the employee immunization rate was 41% for the 2003-2004 influenza season. PROJECT: In the summer of 2004, the infection control and employee health coordinators conducted a survey to determine employees' knowledge and beliefs regarding influenza vaccine, and to identify barriers to immunization. A 32% response rate was received. Only 78% of respondents who were immunized and 63% of respondents who were not immunized believed that influenza immunization was a patient safety issue. Of the 140 respondents who were not immunized, 46% stated they had a fear of side effects, 33% feared getting influenza from the vaccine and 18% did not believe they were at risk of contracting influenza. Due to the vaccine shortage for the 2004 season, the project was put on hold. With the support of administration, increasing the employee influenza immunization rate to 50% became an organizational goal in 2005. An educational program and publicity campaign were designed to address the issues identified in the 2004 survey, employee incentives were offered, and a system was developed to track education and immunization rates. RESULTS: For the 2005- 2006 influenza season, 74% of employees had documentation of education regarding influenza and influenza immunization, and 57% of total staff received influenza vaccine. Review of discipline specific data indicated that staff in some clinical areas, therapeutic services and support services did not reach the 50% goal. LESSONS LEARNED: The survey process proved beneficial in identifying employee misconceptions and targeting these issues through education. Tracking also identified areas where different strategies may be needed to increase immunization rates. The organizational goal for 2006 includes increasing the total percentage of employees immunized to 60%, with focus on the clinical areas.

Immunisation of a cohort Pacific children living in New Zealand over the first 2 years of life

Pacific children have had consistently evidenced low rates for routine childhood immunisations. Using the Pacific Islands Families: First 2 Years of Life cohort study, we investigated the immunisation rate of Pacific infants residing in New Zealand at 24-months postpartum. Full immunisation was reported for 89% of infants, substantially increased from the 53% found in the 1992 national survey and closer to the New Zealand Ministry of Health's target of 95%. Increased parity and maternal smoking were associated with incomplete child immunisation status. Initiatives to increase immunisation rates amongst Pacific children appear to be succeeding and warrant continuation.

Take a Giant Step: Investing in Preschool Education in Emerging Nations

HE SPEED at which globalization and technological innovation have transformed and flattened economic, political, and social relationships in the past decade requires a new approach to investments related to early childhood. While most of the international education and development community, led by UNICEF, has focused during this period on the critical importance of universal primary education, compelling research findings have made it clear that, to serve the long-term interests of emerging nations, a different emphasis is necessary. We must recognize the urgent need for greater investment in preschool education--an essential engine for expanding human potential and accelerating economic in those nations now poised to become the next leaders of the global economy. (1) Increased investment in preschool education is especially important to meet the needs of the world's most populous nations, including China, India, Brazil, and Indonesia. By 2015 these four countries combined will educate more than 10 times the number of children educated in the United States. (2) Many of these nations have made strong commitments to and established early best practices for promoting health and good nutrition but remain far behind more developed countries in their capacity to prepare children for primary school. By building on the findings of experimental research into the elements of high-quality early care and education (ECE) and on our knowledge of how children's minds and bodies learn, grow, and survive, even under adverse conditions, we can now more confidently design new early learning initiatives for use internationally. (3) THE CASE FOR INVESTMENT IN EARLY CARE AND EDUCATION Research in various disciplines has demonstrated how and why high-quality early learning opportunities and activities that promote healthy development matter for children, families, communities, and the society at large. While most of the longitudinal research on early intervention programs has been conducted in the U.S., significant development research in countries like China, India, and Brazil (4) and program evaluations in Europe and Canada have led to similar conclusions. * From birth to age 5, children rapidly acquire capabilities that form the building blocks of their subsequent development. In addition to making remarkable linguistic and cognitive gains at this stage, young children exhibit dramatic progress in constructing their emotional, social, regulatory, and moral capacities. The critical dimensions of early development are intertwined; each requires focused attention. (5) * During a child's early years, a growth in learning, health, and emotional development gains momentum. Interrupting this trajectory can result in the need for powerful and expensive interventions later. (6) * In this era of globalization, many traditional relationships among children, families, schools and other community institutions, and the economy are rapidly transforming, and the needs of young children are not being addressed adequately. (7) * In developing countries, child survival programs that concentrate on reducing infant mortality rates, increasing immunization rates, improving nutrition, and providing clean water and sanitation services have produced long-term economic benefits. (8) In the U.S., high-quality ECE programs have produced significant benefits for low-income families in terms of increased achievement, decreased rates of grade retention, fewer special education referrals, and lower crime, delinquency, and dropout rates. (9) These outcomes indicate that emerging nations could further their development by bolstering their current efforts on behalf of children with more investment in early care and education. EMERGING NATIONS' FIRST STEPS In contrast to the U.S., Canada, and highly developed countries in Europe, most emerging nations have begun only recently to systematically develop and finance educational programs for children aged 3 to 6. …

Patient reminder and patient recall systems to improve immunization rates.

Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result of low immunization rates, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care and large demands on primary care physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g. all children who should receive the measles vaccine) and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g., patient reminders), provider interventions and system interventions. One intervention strategy involves patient reminder and recall systems. To assess the effectiveness of patient reminder and recall systems in improving immunization rates and compare the effects of various types of reminders in different settings or patient populations. A systematic search was performed for the initial review using MEDLINE (1966-1998) and four other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of The Effective Practice and Organisation of Care (EPOC) register in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings and files of study collaborators were also searched for references. In December 2004 the EPOC register was searched to identify relevant articles to update the review. Randomized controlled trials (RCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies written in English. Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting. Any intervention that falls within the EPOC scope (See Group Details) and that includes patient reminder or recall systems, or both, in at least one arm of the study. Immunization rates or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g. influenza vaccination) or standard combinations of recommended vaccinations (e.g. all recommended vaccinations by a specific date or age). Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus. Results are presented for individual studies as relative rates for randomized controlled trials and as absolute changes in percentage points for controlled before and after studies. Pooled results for RCTs only were presented using the random effects model. Five new studies were added for this update. Increases in immunization rates due to reminders were in the range of 1 to 20 percentage points. Reminders were effective for childhood vaccinations (OR = 1.45, 95% CI =1.28, 1.66), childhood influenza vaccinations (OR = 2.87, 95% CI = 1.65, 4.98), adult pneumococcus, tetanus, and Hepatitis B (OR = 2.19, 95% CI = 1.21, 3.99), and adult influenza vaccinations (OR = 1.66, 95% CI = 1.31, 2.09). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but most costly. Patient reminder and recall systems in primary care settings are effective in improving immunization rates within developed countries.