Reminder Systems and Strategies for Increasing Childhood Vaccination Rates

An important component of an immunization provider practice is ensuring that the vaccines reach all individuals who need them. While attention to appropriate administration of vaccinations is essential, it cannot be assumed that these vaccinations are being given to every eligible person at the recommended age.

Specific concerns about U.S. immunization levels and areas for further study include the following:

• Childhood immunization rates are still suboptimal.
• Economic and racial disparities exist.

This page offers many resources and publications describing the need for increasing immunization levels and outlines strategies that providers can adopt to increase coverage in their own practice.

Specific strategies to increase Adult vaccination rates can be found on the Adult Vaccination Information for Healthcare and Public Health Professionals website

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CDC Sources

• "Immunization Strategies": CDC's strategies that lead to high immunization levels in a practice - Chapter 3 in the "Pink Book"
  Explains the need for strategies to increase immunization rates, the AFIX approach (assessment, feedback, incentives, eXchange), and other essential strategies such as recordkeeping, recommendations and reinforcement, reminder and recall to patients and providers, reduction of missed opportunities and barriers to immunization.
• Immunization Information Systems
  Many recordkeeping tasks, as well as patient reminder/recall activities, can be greatly simplified by participation in a population-based immunization information system (IIS), also known as an immunization registry.
• Increasing Appropriate Vaccination: Client Reminder and Recall Systems
  CDC's The Community Guide
  Summary of the Task Force on Community Preventive Services’ Recommendations and Findings covering reviews done between 2014 and 2016.
• Recommendations of the ACIP: Programmatic Strategies to Increase Vaccination Rates -- Assessment and Feedback of Provider-Based Vaccination Coverage Information (published 1996; historical document)

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External Sources

• Checklist: Suggestions to Improve Your Immunization Services [2 pages] June 2008 Immunization Action Coalition
  For healthcare professionals to improve their efficiency in administering vaccines and increase their immunization rates.
• Population vs. Practice-Based Interventions to Increase Immunization Rates in Young Children [23 pages] "October 2012
• Barriers and Strategies to Improving Influenza Vaccination among Health Care Personnel

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Publications/Articles

Cost-effectiveness needs more research, regarding which strategies increase immunization levels with the least expenditure so these strategies can be prioritized.

Sustainable systems for vaccinating children, adolescents, and adults must be developed. High immunization rates cannot rest upon one-time or short-term efforts. Greater understanding of strategies to increase and sustain immunization levels is necessary in order to create lasting, effective immunization delivery systems.

Many strategies have been used to increase immunizations. Some, such as school entry laws, have effectively increased demand for vaccines, but the effectiveness of other strategies (e.g., advertising) is less well documented. Some proven strategies (e.g., reducing costs, linking immunization to Women Infants and Children (WIC) services, home visiting) are well suited to increasing rates among specific populations, such as persons with low access to immunization services.

A selection of the articles published on this topic are listed below. The first three are general reviews, and the remainder are stratified by strategy type.

General

• Increasing Adolescent Immunization Rates in Primary Care: Strategies Physicians Use and Would Consider Implementing. Clin Pediatr. 2013;52(8):710-20
• Increasing Immunization Coverage. Pediatrics. 2010;125:1295-1304
• IDSA's policy to strengthen adult and adolescent immunization coverage. Infectious Diseases Society of America (IDSA) Clin Infect Dis. 2007;44:1529-1531

Strategy Type Representative Articles

Home Visits

• Banach DB, Ornstein K, Factor SH, Soriano TA. Seasonal influenza vaccination among homebound elderly receiving home-based primary care in New York City. J Community Health. 2012;37(1):10-4.
• Szilagyi PG, Humiston SG, Gallivan S, Albertin C, Sandler M, Blumkin A. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Arch Pediatr Adolesc Med. 2011;165(6):547-53.

School requirements

• Bugenske E, Stokley S, Kennedy A, Dorell C. Middle school vaccination requirements and adolescent vaccination coverage. Pediatrics. 2012;129(6):1056-63.
• Hadler JL, Yousey-Hindes K, Kudish K, Kennedy ED, Sacco V, Cartter ML. Impact of requiring influenza vaccination for children in licensed child care or preschool programs—Connecticut, 2012-13 influenza season. MMWR. 2014;63(10):224.

Client/family incentives

• Luthy KE, Thorpe A, Dymock LC, Connely S. Evaluation of an intervention program to increase immunization compliance among school children. Journal of School Nursing. 2011; 27(4):252-7.

Client reminder recall

• Kempe A1, Barrow J, Stokley S, Saville A, Glazner JE, Suh C, et al. Effectiveness and cost of immunization recall at school-based health centers. Pediatrics. 2012 Jun;129(6):e1446-52. doi: 10.1542/peds.2011-2921.
• Kharbanda EO1, Stockwell MS, Fox HW, Andres R, Lara M, Rickert VI. Text message reminders to promote human papillomavirus vaccination. Vaccine. 2011;29(14):2537-41. doi: 10.1016/j.vaccine.2011.01.065.
• Stockwell MS1, Kharbanda EO, Martinez RA, Vargas CY, Vawdrey DK, Camargo S. Effect of a text messaging intervention on influenza vaccination in an urban, low-income pediatric and adolescent population: a randomized controlled trial. JAMA. 2012;307(16):1702-8. doi: 10.1001/jama.2012.502.
• Szilagyi PG, Humiston SG, Gallivan S, Albertin C, Sandler M, Blumkin A. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Archives of Pediatrics & Adolescent Medicine. 2011;165(6):547-53.

Standing Orders

• Melinkovich P, Hammer A, Staudenmaier A, Berg M. Improving pediatric immunization rates in a safety-net delivery system. Joint Commission Journal on Quality & Patient Safety. 2007;33(4):205-10.

Provider reminders

• Patwardhan A, Kelleher K, Cunningham D, Spencer C. Improving the influenza vaccination rate in patients visiting pediatric rheumatology clinics using automatic best practice alert in electronic patient records. Pediatric Rheumatology. 2012;10(Suppl 1):A106.
• Fiks AG, Hunter KF, Localio AR, et al. Impact of electronic health record-based alerts on influenza vaccination for children with asthma. Pediatrics. 2009;124(1):159-69.

Provider feedback

• Brousseau N, Sauvageau C, Ouakki M, et al. Feasibility and impact of providing feedback to vaccinating medical clinics: evaluating a public health intervention. BMC Public Health. 2010;10(1):750.

Special Supplemental Nutrition Program for Women, Infants & Children (WIC) Settings

• Ghosh TS, Patnaik JL, Bennett A, Trefren L, Vogt RL. Assessment of missing immunizations and immunization-related barriers among WIC populations at the local level. Public Health Rep. 2007;122(5):602-6.

Health Care System-Based Interventions Implemented in Combination

• Allison MA, Daley MF, Barrow J, et al. High influenza vaccination coverage in children with high-risk conditions during a vaccine shortage. Archives of Pediatrics & Adolescent Medicine. 2009;163(5):426-31.
• Hambidge SJ, Phibbs SL, Chandramouli V, Fairclough D, Steiner JF. A stepped intervention increases well-child care and immunization rates in a disadvantaged population. Pediatrics. 2009;124(2):455-64.
• Szilagyi PG, Humiston SG, Gallivan S, Albertin C, Sandler M, Blumkin A. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Archives of Pediatrics & Adolescent Medicine. 2011;165(6):547-53.

Community-Based Interventions Implemented in Combination

• Findley SE, Irigoyen M, Sanchez M, et al. Effectiveness of a community coalition for improving child vaccination rates in New York City. American Journal of Public Health. 2008;98(11):1959-62.
• Findley SE, Sanchez M, Mejia M, et al. Effective strategies for integrating immunization promotion into community programs. Health Promotion Practice. 2009;10(Suppl 2):128S-137S.
• Lemstra M, Rajakumar D, Thompson A, Moraros J. The effectiveness of telephone reminders and home visits to improve measles, mumps and rubella immunization coverage rates in children. Paediatrics and Child Health. 2011;16(1):e1-e5.

Reducing Client Out-of-Pocket Costs

• Carpenter LR, Lott J, Lawson BM, Hall S, Craig AS, Schaffner W et al. Mass distribution of free, intranasally administered influenza vaccine in a public school system. Pediatrics 2007;120(1):e172-8.
• Molinari NAM, Kolasa M, Messonnier ML, Schieber RA. Out-of-pocket costs of childhood immunizations: a comparison by type of insurance plan. Pediatrics. 2007;120(5):e1148. http://dx.doi.org/10.1542/peds.2006-3654.

Immunization Information Systems

• Adamkiewicz TV, Silk BJ, Howgate J, Baughman W, Strayhorn G, Sullivan K, et al. Effectiveness of the 7-valent pneumococcal conjugate vaccine in children with sickle cell disease in the first decade of life. Pediatrics. 2008;121(3):562-9.
• Allison MA, Daley MF, Barrow J, Crane LA, Beaty BL, Allred N, et al. High influenza vaccination coverage in children with high-risk conditions during a vaccine shortage. Arch Pediatr Adolesc Med. 2009;163(5):426-31.
• Feemster KA, Spain CV, Eberhart M, Pati S, Watson B. Identifying infants at increased risk for late initiation of immunizations: maternal and provider characteristics. Public Health Rep. 2009;124(1):42-53.
• Guh AY, Hadler JL. Use of the state immunization information system to assess rotavirus vaccine effectiveness in Connecticut, 2006-2008. Vaccine. 2011;29(37):6155-8.
• Papadouka V, Metroka A, Zucker JR. Using an immunization information system to facilitate a vaccine recall in New York City, 2007. J Public Health Manag Pract. 2011;17(6):565-8.
• Saville AW, Albright K, Nowels C, Barnard J, Daley MF, Stokley S, et al. Getting under the hood: exploring issues that affect provider-based recall using an immunization information system. Acad Pediatr. 2011;11(1):44-9.

Schools and Organized Child Care Centers

• Guay M, Clouâtre AM, Blackburn M, et al. Effectiveness and cost comparison of two strategies for hepatitis B vaccination of schoolchildren. Can J Public Health. 2003;94(1):64-7.
• Effler PV, Chu C, He H, et al. Statewide school-located influenza vaccination program for children 5-13 years of age, Hawaii, USA. Emerg Infect Dis. 2010;16(2):244. http://dx.doi.org/10.3201/eid1602.091375.