This is the current release of the guideline.

• Influenza
• Pneumococcal disease
• Hepatitis B

Prevention

Family Practice
Infectious Diseases
Internal Medicine
Preventive Medicine

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Managed Care Organizations
Nurses
Patients
Physician Assistants
Physicians
Public Health Departments

To provide recommendations for use of population-based interventions to improve the coverage of influenza, pneumococcal polysaccharide, and hepatitis B vaccines among adults aged <65 years at high risk, with occupational exposure, risky behavior, or medical conditions (targeted vaccination)

Adults aged <65 years at high risk, with occupational exposure, risky behavior, or medical conditions

1. Interventions to enhance access to vaccination services
   • Expanded access in health-care settings
   • Reducing client out-of-pocket costs
2. Provider- or system-based interventions
   • Standing orders
   • Provider reminder systems
   • Provider assessment and feedback
3. Interventions to increase client demand for vaccination services
   • Client reminder systems
   • Client education
4. Combinations of the interventions listed above

• Coverage rates for influenza, pneumococcal polysaccharide, and hepatitis B vaccines in adult populations <65 years of age at high risk
• Vaccine-preventable disease incidence
• Morbidity and mortality rates for Influenza, pneumococcal disease, and hepatitis B

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Overview of Process

For each Community Guide topic, a multidisciplinary team conducts a review that includes the following steps:

• Developing an approach to organizing, grouping, and selecting the interventions
• Systematically searching for and retrieving evidence
• Assessing the quality and summarizing the strength of the body of evidence on effectiveness
• Translating the body of evidence on effectiveness into conclusions
• Assessing evidence about economic efficiency, applicability, other positive and negative effects, and barriers to implementation (if the effectiveness of the intervention has been established)
• Identifying and summarizing research gaps

Search Strategy

The team used multiple strategies to identify studies of interventions, starting with a search of 12 computerized databases (MEDLINE®, Embase, Psychlit, Sociological Abstracts, CabHealth, HealthStar, AIDSline, Occupational Safety and Health Database, Educational Resource Information Center [ERIC], PsycINFO®, Dissertation Abstracts, and Conference Papers Index).

Team members also reviewed reference lists of published studies and consulted with specialists in the field to identify relevant studies.

Inclusion Criteria

Studies were eligible for inclusion in the reviews of effectiveness if they:

• Were primary investigations of interventions selected for evaluation rather than, for example, guidelines or reviews
• Were published in English during January 1980--August 2001
• Compared outcomes among groups of persons exposed to the intervention with outcomes among groups of persons not exposed or less exposed to the intervention (i.e., the study design included a concurrent or before-and-after comparison)
• Were conducted in established market economies
• Measured differences or changes in vaccination coverage
• Were studies of influenza, pneumococcal polysaccharide, or hepatitis B vaccines
• Were studies of populations that either focused on or included persons aged <65 years and at high risk for infection, morbidity, or mortality

• 2,461 titles and abstracts were identified, of which 60 met the inclusion criteria. Of these, 25 were excluded on the basis of limitations in their design or execution and were not considered further.
• 35 papers were considered qualifying studies

Weighting According to a Rating Scheme (Scheme Not Given)

The strength of the body of evidence of effectiveness was characterized as strong, sufficient, or insufficient on the basis of the number of available studies, the suitability of study designs for evaluating effectiveness, the quality of execution of the studies, the consistency of the results, and a determination of median effect size sufficient for the purpose of public health benefit.

Systematic Review with Evidence Tables

Each study was evaluated by two independent reviewers using a standardized abstraction form and was assessed for suitability of the study design and threats to validity. Studies were characterized as having good, fair, or limited execution on the basis of the number of threats to validity. Studies with greatest or moderate design suitability and a good or fair quality of execution were considered qualifying studies and became part of the body of evidence.

Results for each outcome of interest were obtained from each study that met the minimum quality criteria. For this review, assessment of the effectiveness of an intervention was primarily based on the reported measurements of changes in coverage rates for influenza, pneumococcal polysaccharide, or hepatitis B vaccination. In studies with concurrent comparison groups, the overall change in vaccination coverage was calculated by using the difference in vaccine coverage change observed in the intervention and comparison groups. In studies without a concurrent comparison group (e.g., time series evaluations), the absolute percentage change was calculated from measurements of vaccination coverage in the study population pre- and postintervention. The median was used to summarize a typical measure of effect across the body of evidence for each outcome of interest; both the median and the range are reported. Refer to the original guideline document for detailed description of methods of calculations.

In its earlier review of universally recommended vaccines, the Task Force summarized the evidence on effectiveness of interventions implemented in combination within defined multicomponent categories (e.g., multicomponent interventions that include patient or provider education). The multicomponent body of evidence summarized in the current reviews consisted predominantly of studies evaluating unique, overlapping combinations of interventions. A multicomponent framework was initially developed in these reviews, but the Task Force later determined that a simplified, qualitative, and conceptual categorization of interventions within a "menu" format provides a more accurate and useful assessment of the evidence. Studies with similar but not identical combinations of interventions within or across categories were evaluated together as a body of evidence. Effectiveness was determined for each possible combination of categories. After effective category combinations were identified, specific interventions with sufficient evidence on effectiveness as part of a multicomponent effort were included as category options in the menu. This approach introduces an additional qualitative method for Task Force recommendations while acknowledging the work of previous investigators who developed and implemented intervention combinations on the basis of a conceptual understanding of vaccination demand and delivery.

Other

Task Force recommendations are based primarily on the effectiveness of interventions as determined by the systematic literature review process. In making recommendations, the Task Force balances information about the effectiveness of an intervention with information about other potential benefits and potential harms. To determine how widely a recommendation should apply, the Task Force also considers the applicability of the intervention in various settings and populations. Finally, the Task Force reviews economic analyses of those interventions found to be effective and summarizes applicable barriers to intervention implementation. Economic information is provided to assist the reader with decision making but generally does not affect the Task Force's recommendation.

Strength of Evidence of Effectiveness = Strength of Recommendation

The strength of each recommendation is based on the evidence of effectiveness (i.e., an intervention is recommended on the basis of either strong or sufficient evidence of effectiveness).

If insufficient evidence to determine effectiveness is found, this means that it was not possible to determine whether or not the intervention works based on the available evidence.

The guideline developers reviewed a published cost analysis.

Peer Review

Subject matter experts served as consultants for the review. The Centers for Disease Control and Prevention (CDC) also conducts a peer review for articles published in the Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports series.

The relationship between the strength of evidence of effectiveness and the strength of the recommendation is defined at the end of the "Major Recommendations" field.

Overview

The Task Force on Community Preventive Services conducted systematic reviews to evaluate the effectiveness of interventions to improve targeted vaccination coverage (i.e., coverage with vaccines recommended for some but not all persons in an age range on the basis of risk for exposure or disease) among adults aged <65 years at high risk when implemented alone (single-component interventions) and in combination with other interventions (multicomponent interventions). Three targeted vaccinations recommended for populations at risk are addressed in this review: influenza, pneumococcal polysaccharide, and hepatitis B. The Task Force identified evidence that certain combinations of interventions have improved vaccination coverage.

Recommendations

• To increase targeted vaccination coverage, the Task Force recommends provider reminders, when implemented alone, to improve targeted vaccination coverage.
• The Task Force also recommends a combination of interventions that include selected interventions from two or three categories of interventions (i.e., increasing community demand for vaccinations, enhancing access to vaccination services, and provider- or system-based interventions - see Table below).

Table: Menu format of intervention combinations recommended by the Task Force on Community Preventive Services to increase targeted vaccinations

One or both of these interventions to enhance access to vaccination services:

• Expanded access in health-care settings
• Reducing client out-of-pocket costs

Plus

One or more of these provider- or system-based interventions:

• Standing orders
• Provider reminder systems
• Provider assessment and feedback

And/or

One or both of these interventions to increase client demand for vaccination services:

• Client reminder systems
• Client education

Definitions:

The strength of the body of evidence of effectiveness was characterized as strong, sufficient, or insufficient on the basis of the number of available studies, the suitability of study designs for evaluating effectiveness, the quality of execution of the studies, the consistency of the results, and a determination of median effect size sufficient for the purpose of public health benefit.

Strength of Evidence of Effectiveness = Strength of Recommendation

The strength of each recommendation is based on the evidence of effectiveness (i.e., an intervention is recommended on the basis of either strong or sufficient evidence of effectiveness).

If insufficient evidence to determine effectiveness is found, this means that it was not possible to determine whether or not the intervention works based on the available evidence.

None provided

The recommendations are based on 35 qualifying studies, all of which had good or fair execution quality. In general, the strength of evidence of effectiveness corresponds directly to the strength of recommendations (see the "Major Recommendations" field).

Improved coverage of influenza, pneumococcal polysaccharide, and hepatitis B vaccines among adults aged <65 years at high risk, with occupational exposure, risky behavior, or medical conditions (targeted vaccination)

Not stated

The recommendations in this report represent the work of the independent, nonfederal Task Force on Community Preventive Services (the Task Force). The Task Force is developing the Guide to Community Preventive Services (the Community Guide) with the support of the U.S. Department of Health and Human Services (DHHS) in collaboration with public and private partners. The Centers for Disease Control and Prevention (CDC) provides staff support to the Task Force for development of the Community Guide. The recommendations presented in this report were developed by the Task Force and are not necessarily the recommendations of DHHS, CDC, or other participating groups.

Using the Recommendations in Communities and Health-Care Settings

Evidence reviews can support, but do not replace, the need to conduct local assessments in the process of program planning. Recommendations from the Task Force can assist program planners in matching effective intervention options to local needs, experience, administrative and social structures and regulations, and resources. In addition to the evidence on effectiveness, evidence on applicability can be used to assess the extent to which the interventions reviewed match a particular local situation. Economic evaluations of the recommended intervention and intervention combinations are limited in both quality and quantity.

The evidence on effectiveness identified in the review is divided among three different vaccines, certain targeted populations, and different community and health-care settings. Despite a limited body of evidence for selected conditions, the Task Force recommendations presented in this report should be broadly applicable (with some exceptions). For example, a limited number of studies were identified of population- based interventions to increase vaccination coverage for hepatitis B among health-care workers. Although motivation to be vaccinated might vary with the vaccine (i.e., hepatitis B protects the health-care worker who is vaccinated, whereas influenza vaccine also protects those patients with whom the health-care worker comes in contact), the Task Force recommendation reflects confidence that effective efforts to increase influenza vaccine coverage among health-care workers can also be applicable to efforts to vaccinate health-care workers against hepatitis B virus (HBV).

Community-based options for interventions to increase vaccination coverage of persons at high risk for HBV are one important area in which substantial gaps remain in the evidence on effectiveness. Substantial differences in the hepatitis B vaccination schedule (a series of three injections), the target populations (persons with high-risk behaviors such as injection-drug use), and the settings for intervention (not primary healthcare settings) are unlikely to be overcome through the direct application of health-care system strategies demonstrated to be effective in other targeted vaccination efforts. Effective and recommended health-care--based interventions might not be applicable or might require considerable modification to fit community-based programs to increase HBV coverage in populations at high risk. Practitioners should ensure that interventions are selected or modified to address locally relevant barriers to vaccination. Researchers should consider more studies of this problem.

In 2000, the Advisory Committee on Immunization Practices updated their universal recommendations for annual influenza vaccination to include adults aged 50--64 years. Program planners dedicated to increasing influenza vaccination coverage within this population should consider recommendations from either or both Task Force reviews applicable. For initial efforts, the recommendations in the original, universal review provide effective and flexible intervention options. For enhancing initial program efforts, the information on intervention combinations recommended in this targeted review might be helpful.

Certain studies included in these reviews evaluated interventions or combinations of interventions implemented to increase vaccine coverage among all adult patients within a health-care system (including both patients with universal and high-risk indications). To match effective interventions to local needs, program planning should include an assessment of existing disparities, if any, in vaccine coverage among adult patients with universal and targeted indications.

Staying Healthy

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2005 Apr 1

Task Force on Community Preventive Services - Independent Expert Panel

U.S. Department of Health and Human Services; Centers for Disease Control and Prevention (CDC)

Task Force on Community Preventive Services

Report Prepared By: Bayo C. Willis, MPH, Immunization Services Division, National Immunization Program; Serigne M. Ndiaye, PhD, Global Aids Program/Office of the Director, National Center for HIV, STD, and TB Prevention; David P. Hopkins, MD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office; Abigail Shefer, MD, Immunization Services Division, National Immunization Program

Task Force Chair: Jonathan E. Fielding, MD, Los Angeles Department of Health Services, Los Angeles, California

Task Force Members: Noreen Morrison Clark, PhD, University of Michigan School of Public Health, Ann Arbor, Michigan; John Clymer, Partnership for Prevention, Washington, DC; Kay Dickersin, PhD, Center for Clinical Trials and Evidence-based Healthcare, Brown University, Providence, Rhode Island; Alan R. Hinman, MD, Task Force for Child Survival and Development, Atlanta, Georgia; Robert L. Johnson, MD, New Jersey Medical School, Department of Pediatrics, Newark, New Jersey; Garland H. Land, MPH, Center for Health Information Management and Epidemiology, Missouri Department of Health, Jefferson City, Missouri; Patricia A. Nolan, MD, Rhode Island Department of Health, Providence, Rhode Island; Alonzo L. Plough, PhD, Public Health, Seattle and King County, Seattle, Washington; Nicolaas P. Pronk, PhD, HealthPartners Center for Health Promotion, Minneapolis, Minnesota; Dennis L. Richling, MD, Midwest Business Group on Health, Chicago, Illinois; Barbara K. Rimer, DrPH; School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Steven M. Teutsch, MD, Merck & Company, Inc., West Point, Pennsylvania

Consultants: Robert S. Lawrence, MD, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; J. Michael McGinnis, MD, Robert Wood Johnson Foundation, Princeton, New Jersey; Lloyd F. Novick, MD, Onondaga County Department of Health, Syracuse, New York

Patricia A. Buffler, PhD, University of California, Berkeley; Ross Brownson, PhD, St. Louis University School of Public Health, St. Louis, Missouri; Mary Jane England, MD, Regis College, Weston, Massachusetts; Caswell A. Evans, Jr., DDS, National Oral Health Initiative, Office of the U.S. Surgeon General, Rockville, Maryland; David W. Fleming, MD, CDC, Atlanta, Georgia; Mindy Thompson Fullilove, MD, New York State Psychiatric Institute and Columbia University, New York, New York; Fernando A. Guerra, MD, San Antonio Metropolitan Health District, San Antonio, Texas; George J. Isham, MD, HealthPartners, Minneapolis, Minnesota; Charles S. Mahan, MD, College of Public Health, University of South Florida, Tampa, Florida; Patricia Dolan Mullen, DrPH, University of Texas--Houston School of Public Health, Houston, Texas; Susan C. Scrimshaw, PhD, University of Illinois School of Public Health, Chicago, Illinois; and Robert S. Thompson, MD, Department of Preventive Care, Group Health Cooperative of Puget Sound, Seattle, Washington, also served on the Task Force while the recommendations were being developed.

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI on July 8, 2005. The information was verified by the guideline developer on July 19, 2005.

No copyright restrictions apply.