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Vaccination Programs: Health Care System-Based Interventions Implemented in Combination


What the Task Force Found

About The Systematic Review

The Task Force finding is finding is based on evidence from a Community Guide systematic review completed in 2010 (62 studies; search period 1980-2010) combined with more recent evidence (2 studies; search period 2010-February 2012). This review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to increasing appropriate vaccination. The finding updates and replaces the 2010 finding for Health System-Based Interventions Implemented in Combination [PDF - 611 kB].


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Summary of Results

The systematic review included 64 studies with 76 study arms.

  • Overall change in vaccination rates from the combination of at least two interventions: median increase of 9.0 percentage points (interquartile interval [IQI]: 4 to 21 percentage points; 58 studies, 70 study arms)
    • Increases in vaccination rates were larger when implemented in settings with low rates at baseline.
  • Change in vaccination rates from the combination of at least one intervention each from two or more strategies: median increase of 17.0 percentage points (IQI: 6 to 27 percentage points; 37 studies, 44 study arms)

Summary of Economic Evidence

The five studies that qualified for the economic review assessed various combinations of provider reminders, standing orders, provider assessment and feedback, provider education, and provider incentives. All monetary values are reported in 2012 U.S. dollars.

  • The median intervention cost per person per year was $4 (IQI: $0.84 to $13; 4 studies)
  • The mean cost per additional vaccinated person was $12, ranging from $6 to $21 (3 studies)
  • One study evaluated an intensive intervention that included home visits to immunize and care for newborns. The cost reported in this study is considered an outlier and was not included in the cost estimates provided above.


Based on the settings and populations from included studies, results are applicable to the following;

  • Interventions were implemented in a range of clinical settings, communities, and client populations
  • Combined approaches were effective when delivered to:
    • Children ages 12 years and younger
    • Adults ages 18 to 65 years
    • Older adults ages 65 years and older
  • Urban settings
  • For different vaccines, including:
    • Childhood vaccination series
    • Pneumococcal –adults and children
    • Influenza – adults and children
    • Tetanus booster

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

  • More evidence is needed on the effectiveness of these interventions in rural settings and when used to increase vaccinations recommended for adolescents.
  • Future research on quality improvement activities in these settings should incorporate study periods sufficient to evaluate continuous quality improvement efforts.

Study Characteristics

  • Studies were conducted in urban (34 study arms), rural (1 study arm), and mixed urban, suburban, and rural (9 study arms) settings.
  • Interventions targeted children (29 study arms), adolescents (2 study arms), adults (14 study arms) and older adults (22 study arms).
  • Studies evaluated the following vaccines:
    • Childhood recommended (24 study arms)
    • Influenza - child (5 study arms)
    • Influenza – adult (27 study arms), child (1 study arm)
    • Pneumococcal - adult (19 study arms)
    • Tetanus booster (4 study arms)
    • Adolescent recommended (1 study arm)
  • Nearly one-third of the studies evaluated interventions that targeted populations with low socioeconomic status (22 study arms).