Vaccination Programs: Schools and Organized Child Care Centers

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends school and organized child care center-located vaccination programs based on strong evidence of effectiveness in increasing vaccination rates, and in decreasing rates of vaccine-preventable disease and associated morbidity and mortality.

The updated CPSTF recommendation is based on findings from 27 studies in which vaccination programs in schools or child care centers:

  • Provided vaccinations on site
  • Were administered by a range of providers including school health personnel, health department staff, and other vaccination providers
  • Were delivered in a variety of different school and organized child care settings
  • Delivered one or more of a range of vaccines recommended for children and adolescents, and
  • Included additional components such as education, reduced client out-of-pocket costs, and enhanced access to vaccination services

School- and organized child care center-located vaccination programs may be most useful in improving immunization rates among children and adolescents for new vaccines, and vaccines with new, expanded recommendations (such as the annual immunization for seasonal influenza) where background rates are likely to be very low and improvements in coverage are needed.


Vaccination programs in schools or organized child care centers are multicomponent interventions delivered on-site to improve immunization rates in children and adolescents. These programs include two or more of the following components:
  • Immunization education and promotion
  • Assessment and tracking of vaccination status
  • Referral of under-immunized school or child care center attendees to vaccination providers
  • Provision of vaccinations

Additional components such as reduced client out-of-pocket costs, client incentives, and enhanced access to vaccination services may be provided.

Organized child care centers include non-home day care, nursery or pre-school, and federal Head Start settings for children aged 5 years and younger. In most states, laws establishing vaccination requirements for school and child care center attendance require assessment, documentation, and tracking specific to each vaccine. Vaccination programs considered in this review either expanded the assessment and tracking process to other immunizations or conducted additional interventions. Vaccination programs are often collaborations between the school or child care center and local health departments, private healthcare providers, or community healthcare services.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

About The Systematic Review

The CPSTF finding is based on evidence from two Community Guide systematic reviews published in 2000 (Vaccination Programs in Schools and Vaccination Programs in Childcare Centers; search period 1980-2001) combined with more recent evidence (search period 1997-2009). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to increasing appropriate vaccination.

Summary of Results

Twenty-nine studies qualified for this review.
  • Vaccination rates: median increase of 47 percentage points (interquartile interval [IQI]: 14 to 61 percentage points; 14 studies with 17 study arms)
  • Improvements in vaccination rates were also observed in studies using different measures (5 studies).
  • Rates of disease: 11 studies evaluated morbidity and mortality outcomes of immunization programs in schools (8 studies) and child care centers (3 studies).
    • School vaccination programs showed reductions in the incidence rates of measles and hepatitis B (3 studies).
    • There were changes in a variety of disease outcomes related to the provision of seasonal influenza vaccines (8 studies).
      • Influenza vaccination programs in U.S. schools showed mixed results for self-reported influenza-like illness and rates of absenteeism (4 studies).
      • Of three studies of influenza vaccination programs in day care centers, two showed reductions in rates of acute otitis media (middle ear infection), and one showed reductions in influenza-like illness in the homes of vaccinated children.
      • An increase in mortality rates among younger children following the elimination of a national vaccination requirement and immunization program for school-age children was observed in Japan (1 study)

Summary of Economic Evidence

Ten studies qualified for the review.
  • Overall, they suggest that vaccination programs in schools can be less expensive compared to immunizations provided in healthcare settings due to lower vaccine costs and the averted loss of parental income associated with children’s clinic visits.
  • Only one study evaluated an influenza vaccination program in a child care center.
  • More studies are needed to determine the economic costs and benefits of vaccination programs in child care centers.


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Evidence Gaps

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)
  • More research of vaccination interventions in child care centers is needed to provide additional information on implementation, impact, and economics of vaccination interventions in these settings.
  • Additional research is suggested on ways to sustain vaccination programs in schools and child care centers by addressing challenges with staffing and financing these interventions.
  • Future research also should examine how programs can be best coordinated with vaccination providers in the community, local health departments, and immunization information systems while adhering to the requirements of the Family Education Rights and Privacy Act (FERPA).

Study Characteristics

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Analytic Framework

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Summary Evidence Table

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Included Studies

Economic Review

Carpenter LR, Lott J, Lawson BM, et al. Mass distribution of free, intranasally administered influenza vaccine in a public school system. Pediatrics. 2007;120(1):e172-e8.

Deuson RR, Hoekstra EJ, Sedjo R, et al. The Denver school-based adolescent hepatitis B vaccination program: a cost analysis with risk simulation. Am J Public Health 1999;89(11):1722.

Dilraj A, Strait-Jones J, Nagao M, Cui K, Terrell-Perica S, Effler PV. A statewide hepatitis B vaccination program for school children in Hawaii: vaccination series completion and participation rates over consecutive school years. Public Health Rep 2003;118(2):127.

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.

Guay M, Clou tre 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.

Hibbert CL, Piedra PA, McLaurin KK, Vesikari T, Mauskopf J, Mahadevia PJ. Cost-effectiveness of live-attenuated influenza vaccine, trivalent in preventing influenza in young children attending day-care centres. Vaccine 2007;25(47):8010-20.

Hull HF, Frauendienst RS, Gundersen ML, Monsen SM, Fishbein DB. School-based influenza immunization. Vaccine 2008;26(34):4312-3.

Kansagra SM, McGinty MD, Morgenthau BM, et al. Cost comparison of 2 mass vaccination campaigns against influenza A H1N1 in New York City. Am J Public Health 2011;102(7):1378-83.

Krahn M, Guasparini R, Sherman M, Detsky AS. Costs and cost-effectiveness of a universal, school-based hepatitis B vaccination program. Am J Public Health 1998;88(11):1638.

Luce BR, Zangwill KM, Palmer CS, et al. Cost-effectiveness analysis of an intranasal influenza vaccine for the prevention of influenza in healthy children. Pediatrics 2001;108(2):e24.

Mark H, Conklin VG, Wolfe MC. Nurse volunteers in school-based hepatitis B immunization programs. J Sch Nurs 2001;17(4):185.

Pisu M, Meltzer MI, Hurwitz ES, Haber M. Household-based costs and benefits of vaccinating healthy children in daycare against influenza virus: results from a pilot study. Pharmacoeconomics. 2005;23(1):55-67.

Schmier J, Li S, King JC, Nichol K, Mahadevia PJ. Benefits and costs of immunizing children against influenza at school: an economic analysis based on a large-cluster controlled clinical trial. Health Aff 2008;27(2):w96.

Sweet L, Gallant P, Morris M, Halperin SA. Canada’s first universal varicella immunization program: Lessons from Prince Edward Island. Can J Infect Dis 2003;14(1):41.

Tran CH, McElrath J, Hughes P, et al. Implementing a community-supported school-based influenza immunization program. Biosecur Bioterror 2010;8(4):331-41.

Wallace LA, Young D, Brown A, et al. Costs of running a universal adolescent hepatitis B vaccination programme. Vaccine 2005;23(48-49):5624-31.

Wilson T. Economic evaluation of a metropolitan wide, school based hepatitis B vaccination program. Public Health Nurs 2000;17(3):222-7.

Additional Materials

Hong K, Leidner AJ, Tsai Y, Tang Z, Cho B, Stokley S. Costs of interventions to increase vaccination coverage among children in the United States: a systematic review. Academic Pediatrics 2021;21(4):S67-77.

Search Strategies

Economic Review

The present review included studies that reported economic outcomes from the 2000 review (search period 1980-1997) combined with studies identified from updated searches (search period 1997- February 2012) within the standard medical and health-related research databases, Google Scholar, and databases specialized to economics and social sciences. The details of the two sets of searches are provided below.

Details of the Updated Search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing interventions to improve vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. In addition, Google Scholar and specialized databases (CRD-University of York: NHS EED, EconLit, and JSTOR), were also searched. Reference lists of articles reviewed as well as lists in review articles were also considered, and subject matter experts consulted for additional references.

Search Terms

  • Immunization
  • Vaccination
  • Immunization Programs

To be included in the updated review, a study had to do the following:

  • Have a publication date of 1997- February 2012
  • Evaluate vaccinations with universal recommendations
  • Meet the evidence review and Community Guide review team’s definition of the interventions
  • Be a primary research study with one or more outcomes related to the analytic framework(s)
  • Take place in a high income country or countries
  • Be written in English; and
  • Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed.
Details of the Original Search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included, a study had to do the following:

  • Have a publication date of 1980 1997
  • Address universally recommended adult, adolescent, or childhood vaccinations
  • Be a primary study rather than, for example, a guideline or review
  • Take place in an industrialized country or countries
  • Be written in English
  • Meet the definition of the interventions
  • Provide information on one or more outcomes related to the analytic frameworks; and
  • Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.