United States General Accounting Office

GAO Report to Congressional Requesters

June 1995 IMMUNIZATION

HHS Could Do More to

Increase Vaccination

Among Older Adults

GAO/PEMD-95-14

GAO United States

General Accounting Office

Washington, D.C. 20548

Program Evaluation and

Methodology Division

B-254782 

June 8, 1995

The Honorable John H. Chafee

Chairman, Subcommittee on Medicaid and

 Health Care for Low-Income Families

Committee on Finance

United States Senate

The Honorable Judd Gregg

Chairman, Subcommittee on Aging

Committee on Labor and Human Resources

United States Senate

Although Medicare covers pneumococcal and influenza vaccination, rates of immunization

among the elderly are low and significant mortality persists. At your request, we studied these

immunization rates, the resources the Department of Health and Human Services (HHS) has

expended on monitoring and improving the use of these vaccines, and the types of interventions

that enhance the use of these vaccines. We are pleased to present our findings in this report.

As discussed with your offices, unless you publicly announce its contents earlier, we plan no

further distribution of this report until 30 days from its date of issue. We will then send copies

to the Secretary of Health and Human Services, the Administrator of the Health Care Financing

Administration (HCFA), the Director of the U.S. Public Health Service (PHS), the Director of the

Centers for Disease Control and Prevention (CDC), and other interested parties. We will also

make copies available to others on request.

If you have any questions or would like additional information, please call me at (202) 512-3092.

Other major contributors to this report are listed in appendix VI.

Kwai-Cheung Chan

Director of Program Evaluation

 in Physical Systems Areas
Executive Summary

Purpose Pneumococcal and influenza-associated diseases are the leading causes of

vaccine-preventable death in the United States. On average, 32,800 people

die from pneumococcal disease and 20,000 die from influenza each year.

The elderly suffer the most from these diseases and the costs to the

federal government are substantial. Annual Medicare hospital

reimbursement ranges between $500 million and $1 billion for the

treatment of influenza-associated illnesses alone. At the request of

Senators Chafee and Gregg, GAO reviewed immunization rates among the

elderly for flu and pneumococcal disease, the efforts and resources HHS

has devoted to improving these rates, and the types of interventions that

enhance the use of these vaccines.

Background The PHS Advisory Committee on Immunization Practices (ACIP) and

professional medical organizations recommend one-time pneumococcal

vaccination and annual flu shots for all persons 65 years or older and for

nonelderly persons in high-risk groups, such as persons with heart or lung

disease. Safe and effective vaccines are now covered under Medicare;

nonetheless, the 1993 National Health Interview Survey (NHIS) indicates

that immunization rates for these diseases were below the national goals

set by HHS as long ago as 1980.

Results in Brief Although reported use of pneumococcal and influenza vaccines among the

elderly has more than doubled in the past 10 years, immunization rates for

both diseases remain low, and morbidity as well as mortality remain

significant. Pneumococcal disease is associated with higher mortality than

influenza, yet pneumococcal immunization rates are lower. Nonetheless,

in the 14 years since authorization of Medicare coverage for

pneumococcal vaccination, HHS has conducted few activities to enhance its

use aside from providing Medicare payment. Antibiotic resistance of

pneumococcal bacteria is increasing, yet reaching HHS’ 60-percent

vaccination goal for the year 2000 appears unlikely based on current

trends. In contrast, in the short time since Medicare began national

coverage for influenza vaccination, HHS has made significant efforts to

enhance the use of this vaccine. The pace of increase in influenza

vaccination rates since 1989, HHS’ plans to enhance its promotional

strategies, and preliminary data cited by the agency are promising,

suggesting that the 60-percent flu immunization goal for the year 2000 may

be attained.

Page 2 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Executive Summary

Although immunization rates are low, CDC spends very little promoting

pneumococcal and influenza vaccination. GAO believes that increasing

promotion efforts would increase immunization rates and thus save lives.

But HHS maintains that the appropriations report language pertaining to

CDC strongly discourages the Department from spending more of its

immunization funding on the elderly. GAO does not agree that the

legislative history dictates CDC’s small level of spending on adult

immunization. GAO reviewed the records of appropriations hearings and

found that HHS has not taken a leadership role in defining pneumococcal

and influenza immunization as important public health issues for the

Congress and in seeking funding commensurate with their significance.

To increase vaccination rates, GAO concludes that efforts to improve health

care providers’ compliance with adult immunization guidelines are more

promising than attempts to influence consumers’ knowledge and attitudes.

Physicians have a strong impact on consumers’ vaccination decisions, but

they often fail to recommend vaccination to those patients for whom it is

indicated. Computer-based reminder systems, checklists appended to

medical records, practice-based tracking systems, and issuance of

standing orders for vaccination help to remedy this problem. The

broad-based implementation of a hospital policy to vaccinate eligible

high-risk patients before discharge shows much promise to reduce

vaccine-preventable mortality among adults.

Principal Findings

Immunization Rates Are

Low

HHS currently relies principally on the National Health Interview Survey to

monitor rates of vaccination. The most recent available data (from the

1993 NHIS) indicate that 73 percent of older Americans had never received

the pneumococcal vaccination, despite its coverage under Medicare since

1981, and 49 percent of the elderly had not been vaccinated against

influenza during the 1992-93 flu season preceding Medicare coverage.1

Elderly blacks are between one-third and one-half as likely as older whites

to get vaccinated, and persons with high-risk medical conditions or

activity limitations or who describe their health as poor are generally

somewhat more likely to get vaccinated. Also, elderly persons who had not

1

In comments on a draft of this report, HHS cites “preliminary” data from a survey of Medicare

beneficiaries indicating 60.8 percent received a flu shot in the 1993-94 flu season. This is about

10 percentage points higher than the rate for the previous season, as estimated by the 1993 NHIS, but

consistent with the upward trend in flu immunization rates since the mid-1980s.

Page 3 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Executive Summary

visited a doctor in the last year were less than one-quarter as likely to have

gotten either vaccine compared with those who had three or more doctor

visits. Nonetheless, even persons with five or more doctor visits were

unlikely to have received pneumococcal vaccination.

HHS’ Vaccination

Strategies and Resource

Allocations Are Inadequate

HHS officials acknowledge and agency documents reflect the significance

of the public health problem presented by both illnesses. However, GAO

found that HHS has taken few steps to improve pneumococcal vaccine use

since Medicare coverage for the vaccine was authorized in 1981. By

comparison, HHS has done more in its recent efforts to improve the use of

flu vaccine. When Medicare coverage for influenza vaccination began in

1993, HCFA initiated a public information campaign through the mass

media. In fiscal 1995, HCFA enhanced this effort by making data on state

and county immunization rates available to health care providers and

beginning limited activities through the agency’s peer review

organizations.

Among the HHS agencies we reviewed, HCFA makes the bulk of federal

expenditures directly linked to pneumococcal and influenza immunization,

primarily as Medicare payments (about $100 million in fiscal 1994).

Although CDC distributed 94 percent of its $528 million fiscal 1994

immunization budget to the National Immunization Program (NIP), less

than 1 percent of these funds were dedicated to adult immunization

activities. The number of NIP staff positions dedicated to adult

immunization activities remained constant, at five, between 1987 and 1994,

when it increased to seven.

Provider-Focused

Strategies Show Promise

for Improving

Immunization

Strategies that show documented promise for enhancing pneumococcal

and influenza vaccine use include physician reminder systems, the

issuance of standing orders for immunizing patients, and systems for

tracking patients in need of immunization. Well-designed reminders to

potential vaccinees were also found to be effective. Although vaccination

clinics and public information campaigns have been part of successful

efforts to improve vaccination rates, the independent effects of these

strategies have not been rigorously evaluated.

Research suggests that a policy to vaccinate eligible patients before

hospital discharge shows significant promise for reducing pneumococcal

disease. Studies conducted in the United States, Canada, and the United

Kingdom show that a majority of patients admitted to hospitals with

Page 4 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Executive Summary

pneumococcal disease had been discharged from a hospital within the

previous 5 years (and had thus missed an important vaccination

opportunity). ACIP has recommended that pneumococcal vaccine be

offered routinely to hospitalized patients in high-risk groups before

discharge to prevent future admissions for pneumococcal disease, but the

data suggest that this policy has not been widely implemented.

Recommendations GAO recommends that the Secretary of HHS take a more active leadership

role in promoting pneumococcal and influenza vaccination among elderly

persons by (1) seeking, in the annual appropriations process, to clarify

what proportion of immunization funding should be allocated for such

activities; and (2) directing HCFA and PHS to focus their efforts on

promoting or supporting promising strategies, such as patient and

physician reminder systems, development of standing order policies, and

broad-based use of a hospital policy to vaccinate eligible patients before

discharge.

Agency Comments Responsible officials from HHS provided written comments on a draft of

this report, which are reproduced in appendix V. The Department also

provided technical comments, which are addressed in the body of the

report as appropriate.

The Department generally agreed with GAO that more effort is needed to

increase rates of immunization among the elderly. Following their review

of our report, HHS officials told us that in fiscal 1997, CDC plans to propose

an initiative in this area. However, the Department did not agree with our

first recommendation. HHS stated that the Congress has previously guided

CDC to place priority on childhood immunization. However, GAO concluded

that one reason why the Congress has not emphasized a public health role

in adult immunization is because HHS has not taken a leadership role in

promoting its importance.

With respect to the second recommendation, HHS does not question the

effectiveness or practicality of the strategies GAO identified. However, the

Department does not specify what steps it will take to support or

encourage use of these strategies, instead emphasizing its plans to

enhance provider and beneficiary awareness of the benefits of

vaccination. Yet, GAO found that such efforts are not among the most

promising means of increasing immunization rates against these diseases.

Page 5 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Contents

Executive Summary 2

Chapter 1 

Introduction

10

Background 10

Scope and Methodology 15

Chapter 2 

Methods and Results

of Monitoring

Immunization Rates

17

Methods of Monitoring Immunization Rates 17

Immunization Rates: Trends and Correlates 19

Summary 25

Chapter 3 

Agency Immunization

Strategies

27

Activities to Improve Immunization Rates 27

Resources 31

Summary 32

Chapter 4 

Factors That May

Explain Low

Immunization Rates

34

Influences on Vaccine Consumers’ Behavior 34

Influences on Providers’ Behavior 36

Summary 41

Chapter 5 

Promising

Immunization

Strategies

43

Reminder Contacts With Potential Vaccinees 43

Physician Reminder Systems 43

Standing Orders for Vaccination 44

Practice-Based Tracking Systems 45

Other Strategies 45

Summary 46

Chapter 6 

Conclusions and

Recommendations

48

Conclusions 48

Recommendations 50

Agency Comments and Our Response 50

Appendixes Appendix I: HHS Data Collection on Factors That Influence

Vaccine Consumers’ Behavior

54

Page 6 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Contents

Appendix II: HHS Data Collection on Factors That Influence

Vaccine Providers’ Behavior

56

Appendix III: Sample Notice of Medicare Coverage for Influenza

Vaccine Incorporated in Mailings Associated With Medicare

Claims

58

Appendix IV: Administrator’s Letter to Beneficiaries During the

Medicare Influenza Demonstration

59

Appendix V: Comments From the Department of Health and

Human Services

60

Appendix VI: Major Contributors to This Report 66

Tables Table 1.1: Annual Prevalence of Pneumococcal Disease and

Death

11

Table 2.1: Surveys Used to Monitor Adult Immunization Rates 17

Table 2.2: 1991 Immunization Rates by Demographic and Health

Characteristics of Vaccinees

22

Table 2.3: Logistic Regression Predicting Pneumococcal and

Influenza Vaccination Among Persons Age 65 and Older

24

Table I.1: HHS Data Collection on Factors That Influence Vaccine

Consumers’ Behavior

54

Table I.2: Medicare Beneficiaries’ Reasons for Not Receiving

Influenza Vaccine

55

Table II.1: HHS Data Collection on Provider-Based Influences on

Vaccination

56

Figures Figure 2.1: Influenza Vaccination Rates for Persons Age 65 and

Older

20

Figure 2.2: Cumulative Pneumococcal Vaccination Rates for

Persons Age 65 and Older

21

Figure 4.1: Relationship Between Physician Recommendation

and Immunization Rates

39

Page 7 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Contents

Abbreviations

ACIP Advisory Committee on Immunization Practices

BRFSS Behavioral Risk Factor Surveillance Survey

CDC Centers for Disease Control and Prevention

HCFA Health Care Financing Administration

HHS Department of Health and Human Services

HMO Health maintenance organization

NCHS National Center for Health Statistics

NCID National Center for Infectious Diseases

NHIS National Health Interview Survey

NIA National Institute of Aging

NIP National Immunization Program

NVAC National Vaccine Advisory Committee

NVPO National Vaccine Program Office

ORC Opinion Research Corporation

OTA Office of Technology Assessment

PHS Public Health Service

USIS United States Immunization Survey

VA Department of Veterans’ Affairs

Page 8 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Page 9 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 1 

Introduction

Medicare covers vaccines against two types of disease that are hazardous

to the health of elderly persons—pneumonia (and other pneumococcal

infections) and influenza. Although these vaccines are officially

recommended for all persons over 65 and for younger persons with

high-risk conditions, large proportions of those at risk of morbidity and

mortality from these diseases do not receive inoculations against them.

Consequently, Senators Chafee and Gregg asked us to assess HHS’ efforts

to improve these vaccination rates. Below, we describe these diseases, the

safety and efficacy of the vaccines, and our approach to assessing HHS’

activities to improve pneumococcal and influenza vaccination rates.

Background

Pneumococcal Disease and

Influenza

Pneumonia and influenza are the sixth most common cause of death in the

United States. Between 15 and 50 percent of all adult pneumonias are

caused by pneumococcal bacteria, and these infections are the leading

cause of pneumonia requiring hospitalization. In addition to pneumonia,

pneumococcal bacteria can cause serious infections of the bloodstream

(bacteremia) and the covering of the brain or spinal cord (meningitis).

Influenza is a highly contagious viral disease that is spread by direct

contact with an infected person or through contact with the airborne

virus. The public health significance of influenza vaccination derives from

the rapidity with which flu epidemics evolve, the widespread morbidity

associated with these epidemics, and the seriousness of complications

(notably, pneumonias) that may result from the flu. Influenza viruses

continually change over time; thus, people are susceptible to influenza

infection throughout life.

Health Consequences Despite antibiotic therapy, pneumococcal disease remains a leading cause

of morbidity and mortality.1 CDC estimates that there are 268,000 cases of

pneumococcal disease per year in the United States among the

approximately 36 million persons 65 years old or older and that, on

average, 32,800 elderly persons die each year from pneumococcal disease.

People older than 65 are more likely to contract pneumococcal disease

than the general population. (See table 1.1.)

1

According to case studies by the Office of Technology Assessment (OTA) published in 1979, early

enthusiasm for pneumococcal vaccines waned with the introduction of antibiotics, which allowed

doctors to treat disease, thereby alleviating dependence on prevention. Recently, however, antibiotic

resistance of certain types of pneumococci has accelerated significantly.

Page 10 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 1 

Introduction

Table 1.1: Annual Prevalence of

Pneumococcal Disease and Deatha Number of

Disease Cases Deaths

Pneumonia 250,000 25,000

Bacteremia 17,000 7,300

Meningitis 1,000 500

Total 268,000 32,800

aEstimates for persons 65 years of age and older provided by the Division of Bacterial and

Mycotic Diseases, National Center for Infectious Diseases, CDC, 1994.

The incidence of influenza varies from year to year depending on the type

of viral outbreak and its level of activity.2

 The highest illness rate occurs

with the A(H3N2) virus, which has caused epidemics every other year in

the last decade. According to CDC, 5 to 10 percent of the elderly population

become ill with influenza during A(H3N2) outbreaks. On average, type A

and B viruses caused 20,000 deaths per year in the last two decades, with

80 to 90 percent of deaths occurring among the elderly.

Disease Costs Precise annual costs for treating pneumococcal disease and influenza are

not available. However, HCFA researchers have estimated that Medicare

reimburses hospitals $750 million to $1 billion for the treatment of

influenza-associated illness during epidemic periods and almost a half

billion dollars in a nonepidemic year. The majority of cases of

pneumococcal disease and influenza are treated in outpatient settings, and

these estimates do not include the medical costs associated with

outpatient treatment. In fiscal 1994, HHS officials reported expending

approximately $100 million on Medicare coverage for pneumococcal and

influenza vaccines and their administration.

Vaccine Safety and

Efficacy

Pneumococcal Vaccine Mild side effects, such as swelling and pain at the injection site, occur in

about half of the people who are given the pneumococcal vaccine.

However, fever, muscle pain, and more serious local reactions have been

reported in less than 1 percent of recipients.

2

There have been three influenza pandemics this century: “Spanish flu” (1918-19), which caused

500,000 deaths in the United States and 20 million deaths worldwide; “Asian flu” (1957-58), which

caused 70,000 deaths in the United States; and “Hong Kong flu” (1968-69), which caused 34,000 deaths

in the United States.

Page 11 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 1 

Introduction

The efficacy of pneumococcal vaccine has increased over the years as new

vaccines were introduced to protect against a larger number of

pneumococci (83 types are known). The current pneumococcal vaccine,

which became available in 1983, protects against 23 types responsible for

approximately 90 percent of the pneumococcal bacteremic infections

found in U.S. residents.

Randomized controlled trials have demonstrated that the vaccine

protected against pneumococcal infections in healthy young adults in

settings outside the United States where there were high rates of

pneumococcal disease. Recently, a large randomized controlled trial

conducted in France found that the vaccine was 77-percent effective in

reducing the incidence of pneumonia in persons living in geriatric

hospitals and homes for the aged.

In contrast, three major trials with older U.S. adults—in a prepaid medical

plan in San Francisco, in a chronic disease hospital, and in a Department

of Veterans’ Affairs (VA) study—have not demonstrated pneumococcal

vaccine efficacy in preventing pneumococcal pneumonia in the absence of

bacteremia. However, because the rate of pneumococcal infection is quite

low, it is difficult to demonstrate vaccine efficacy in a randomized trial.3

Owing to the difficulties inherent in assessing pneumococcal vaccine

efficacy for older persons from randomized trials, findings from

case-control studies and cohort analyses have become the standard from

which CDC scientists and other experts judge vaccine efficacy. Together,

these studies indicate an overall protective efficacy against invasive

pneumococcal infection of 60 percent to 70 percent in elderly persons with

normal immune response, regardless of such high-risk conditions as heart

or lung disease.

Influenza Vaccine Although most individuals have no side effects from influenza vaccines,

some may have soreness at the injection site or may experience fever or

body aches for a day or two. Unlike the 1976 “swine flu” vaccine, recent flu

shots have not been linked to Guillian-Barré syndrome. According to CDC,

3

For example, the frequently cited VA study has received three main criticisms. First, critics argue that

the randomization process was flawed because the experimental group was significantly different

from the control group on several important study variables. Second, they note that bronchitis (which

accounts for almost half of all pneumococcal infections the study considered as outcome events) was

an inappropriate outcome variable because pneumococcal vaccine is not generally expected to protect

against bronchitis—only pneumonia and bacteremia are well-accepted outcome measures. Third,

given infection rates of 60 per 100,000 persons age 65 or older for bacteremia and between 300 and 600

per 100,000 persons for pneumonia, very large samples are needed to derive statistically meaningful

conclusions. Because the size of the sample used in the VA study was relatively small, the study had

only a 6-percent chance to detect a vaccine efficacy of 65 percent against pneumococcal bacteremia.

Page 12 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 1 

Introduction

the vaccines produced before the mid-1960s were not as purified as

today’s vaccines, and they sometimes produced fever, headache, muscle

ache, and fatigue. These symptoms are similar to those occurring with

influenza, thus some people believed that the vaccine had caused them to

get the flu. Contrary to myth, it has never been possible to get the flu from

influenza vaccines licensed in the United States because they have only

been made from killed (inactivated) viruses, which cannot cause infection.

Influenza vaccine efficacy depends on many factors, including the age and

health status of the recipient and the match between the prevalent flu

strain and the strains addressed in the year’s vaccine. Studies of healthy

young adults have shown influenza vaccine to be 70- to 90-percent

effective in preventing illness. However, in the elderly, the vaccine is often

more effective in reducing the severity of illness and the risk of serious

complications and death than in preventing illness altogether. Studies have

shown the vaccine to reduce hospitalization by about 70 percent and death

by about 85 percent in noninstitutionalized elderly. Among nursing home

residents, vaccine can reduce the risk of hospitalization for flu by about

50 percent, the risk of pneumonia by about 60 percent, and the risk of

death by 75 to 80 percent.

Vaccination

Recommendations

Both pneumococcal and influenza vaccinations are recommended for

elderly persons by U.S. public health authorities. Since 1963, CDC’s

Advisory Committee on Immunization Practices has recommended annual

vaccination against influenza for persons age 65 and older. In 1984, ACIP

began recommending a one-time pneumococcal vaccination for older

persons. In 1989, ACIP also recommended revaccination of persons at

highest risk of fatal pneumococcal infection and those with rapid loss of

pneumococcal antibody levels for whom 6 or more years had passed since

initial vaccination.

Both vaccinations are also recommended for nonelderly persons with

medical conditions that make them vulnerable to severe complications

from influenza infections or that put them at increased risk of

pneumococcal disease. Moreover, ACIP, noting research that shows that

two-thirds of persons with serious pneumococcal disease had been

hospitalized in the 5-year period before the illness, recommends that

pneumococcal vaccine be given to hospitalized patients in high-risk groups

before discharge in order to prevent future admissions for pneumococcal

disease.

Page 13 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 1 

Introduction

Consistent with these professional recommendations, HHS has established

goals for increasing these vaccination rates by the year 2000 to 60 percent

of the population defined by ACIP, which includes all persons age 65 and

older, and at least 80 percent of institutionalized chronically ill or older

persons. The goal of immunizing 60 percent of the elderly with influenza

vaccine is carried over from a 1990 target set by the Surgeon General in

1980.

Legislative Authorization

for Immunization Activities

In July 1981, coverage for pneumococcal vaccine and its administration

became one of the first primary preventive services added to the Medicare

program. It was incorporated in title XVIII of the Social Security Act

following a 1979 study by the Office of Technology Assessment that

indicated pneumococcal vaccination would be cost-effective for persons

age 65 and over.4

OTA issued another report, in 1981, that found that influenza vaccination

for persons age 65 and older would be cost-effective.5

 In Public Law

100-203, the Congress mandated that HCFA conduct a demonstration

project regarding Medicare coverage of influenza vaccination, which

subsequently yielded mixed findings on the cost-effectiveness of flu

coverage.6

 According to legislative mandate, HCFA initiated Medicare

coverage for the vaccine and its administration in May 1993. Consequently,

today Medicare Part B covers both the cost and the administration of

vaccines against pneumococcal disease and influenza for both elderly and

disabled beneficiaries. Unlike most other part B services, for which

beneficiaries must pay 20 percent of allowed charges, no copayment is

required for these two services.7

 Providers’ claims for delivering these

services are processed by a network of carriers and intermediaries

contracted to HCFA, who are also responsible for educating providers about

covered services.

In addition to HCFA, which administers Medicare, two other HHS units

within the Public Health Service have major legislative authority for

immunization activities: the National Vaccine Program Office and the

4

OTA. A Review of Selected Federal Vaccine and Immunization Policies: Based on Case Studies of

Pneumococcal Vaccine. Washington, D.C.: Sept. 1979.

5

OTA. Cost-Effectiveness of Influenza Vaccination. Washington, D.C.: Dec. 1981.

6

Abt Associates, Inc. Medicare Influenza Vaccine Cost-Savings Study: Evaluation Report. Cambridge,

Mass.: Mar. 22, 1993.

7

Providers who do not accept assignment may bill beneficiaries for 15 percent more than the Medicare

allowance.

Page 14 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 1 

Introduction

Centers for Disease Control and Prevention. NVPO was established within

the Office of the Assistant Secretary for Health by the National Childhood

Vaccine Injury Act of 1986 (P.L. 99-660), which added title XXI to the

Public Health Service Act. The office’s responsibilities extend to

coordination of the various federal agencies involved in immunization

activities, including the CDC, and its prescribed roles include coordinating

and directing federal activities relating to vaccine research, distribution,

and use. As authorized by section 317 of the Public Health Service Act, CDC

provides immunization assistance in the form of grants to states and other

public entities and conducts research activities.

Scope and

Methodology

Scope We limited our review of HHS’ immunization strategies to pneumococcal

and influenza vaccination because both are covered under Medicare, both

are recommended for all persons 65 years of age or older, and both cause

significant morbidity and mortality among elderly persons.

Federal responsibilities and activities related to utilization of

pneumococcal and influenza vaccines among the elderly are spread across

a number of departments, agencies, and offices. We focused our review

principally on three HHS units:

• the Health Care Financing Administration, which administers the Medicare

program;

• the National Vaccine Program Office within the PHS’ Office of the Assistant

Secretary for Health, which has been charged with coordinating the

immunization activities of many federal agencies, offices, and departments

to achieve optimal prevention of infectious diseases through

immunization; and

• the CDC’s National Immunization Program, which conducts research and

provides grants and other assistance for state and local immunization

activities.

Methodology To assess the methods and resources HHS uses to monitor and improve

levels of immunization among Medicare beneficiaries, we conducted

interviews with officials at NIP, NVPO, and relevant HCFA offices. We also

Page 15 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 1 

Introduction

attended meetings of the NVPO’s National Vaccine Advisory Committee and

examined relevant promotional materials, reports, budgets, and enabling

legislation.

We examined HHS’ analyses of characteristics of immunized and

nonimmunized elderly persons, including published and unpublished

papers, technical documents, conference presentations, and statistical

results from computer runs. To determine why pneumococcal and

influenza immunization levels are low, we reviewed literature and

consulted immunization experts. We used standard statistical and

scientific principles to evaluate HHS’ methods and to assess the strength of

evidence supporting various interventions.

We conducted our review in accordance with generally accepted

government auditing standards. We did not independently verify or

statistically process the data CDC provided to us.

Page 16 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 2 

Methods and Results of Monitoring

Immunization Rates

Methods of

Monitoring

Immunization Rates

HHS has relied principally on household surveys to estimate national rates

of pneumococcal and influenza immunization among noninstitutionalized

adults. Other information bearing on pneumococcal and influenza vaccine

use is available from CDC’s collection of manufacturers’ quarterly reports

of doses distributed and from records of vaccination claims submitted to

HCFA for Medicare reimbursement.1

Past and Present Survey

Methods

As shown in table 2.1, since 1964, HHS has used a sequence of three

different surveys to monitor pneumococcal and influenza immunization

rates at various intervals: a supplement to the Current Population Survey

known as the United States Immunization Survey (USIS), the Behavioral

Risk Factor Surveillance Survey (BRFSS), and supplements to the National

Health Interview Survey. The NHIS data come from respondents’ reports of

their own and family members’ immunization status when asked, “During

the past 12 months—that is, since (date) a year ago—have any adults in

the family received a flu shot?” and “Have any adults in the family ever

received a pneumonia vaccine?”

Table 2.1: Surveys Used to Monitor

Adult Immunization Rates Years data were collected

Survey Influenza Pneumococcus Sampling frame

USIS 1964

1969-85

1985 Civilian, noninstitutionalized U.S.

population

BRFSS 1987

1993

1993 31 states and D.C. in 1987 and 49

states in 1993

NHIS 1989 

1991 

1993

1989 

1991 

1993

Civilian, noninstitutionalized U.S.

population

Source: CDC/NIP, 1993.

Survey Limitations The survey data from the NHIS are currently the best available national

information on pneumococcal and influenza immunization rates. However,

we did identify some limitations of HHS’ current survey methodology. For

reasons of economy and efficiency, information on different medical

conditions is collected from different subsets of the NHIS sample. Data on

1

Since completion of our review, HCFA has gathered information on Medicare beneficiaries’ receipt of

influenza immunization during the 1993-94 flu season through its 1994 Current Beneficiary Survey.

However, these data were described as “preliminary” on Mar. 27, 1995, when the agency provided

comments on our draft report. We did not review these data and the precision of estimates produced

by the survey. Agency officials told us that preliminary findings indicated that the flu immunization

rate for Medicare beneficiaries has topped 60 percent, but that the pneumococcal immunization rate

remains at 28 percent.

Page 17 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 2 

Methods and Results of Monitoring

Immunization Rates

the two major high-risk conditions for pneumococcal and influenza

disease—heart and lung disease—are collected from separate subsamples,

each comprised of one-sixth of the total sample. This design limits the

factors that may be included in analyses to improve understanding of the

root causes of underimmunization among elderly persons with high-risk

conditions or multiple risk factors. We raised this issue in a meeting with

HHS officials in August 1994 and were told that the 1995 NHIS would be

modified to address this problem.

A second potential limitation of HHS’ method of monitoring immunization

rates concerns the lack of information on the accuracy with which

respondents report their own or household members’ vaccination status.2

Insofar as trends in NHIS data are generally consistent with trends in other

indicators of vaccine use (discussed below), we do not view this as a

serious problem for current applications. However, the extent of

downward or upward bias in self-reported rates might be assessed by

examining self-reports for a sample of individuals whose immunization

status is known through other means.

Finally, HHS lacks recent data on the immunization status of the

institutionalized elderly, such as nursing home residents, who are an

important segment of the 85 and older age group and who are also at high

risk of complications from pneumococcal and influenza disease. Such data

could be useful, not only in monitoring immunization objectives, but also

in assessing the quality of care offered by particular facilities. In response

to our draft report, Department officials noted that the National Center for

Health Statistics will begin to collect data on influenza and pneumococcal

vaccination from a sample of nursing homes in 1995 and every other year

thereafter.

Supplemental Data HHS maintains two data systems that can be used to supplement its

survey-based estimates of immunization rates. CDC’s vaccine surveillance

system, based on manufacturers’ quarterly reports of vaccine distributed

and returned, provides a rough indicator of national vaccine use. In

addition, HCFA’s National Claims History File contains information on

Medicare reimbursement for pneumococcal and influenza vaccinations.

2

NIP and National Center for Health Statistics (NCHS) researchers have also noted the lack of studies

assessing the accuracy of self-reported immunization status for pneumococcal and influenza disease.

See Desiree Rodgers et al., Division of Immunization, CDC and NCHS, “Influenza and Pneumococcal

Vaccination in the Elderly: Results of the 1989 National Health Interview Survey,” presentation made

to the 1991 annual meeting of the American Public Health Association and to the 1992 CDC Epidemic

Intelligence Service Conference.

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Immunization Rates

Although these claims data are not susceptible to the limitations of

self-reported survey data, they suffer from other limitations that restrict

their utility for calculating immunization rates.3

Immunization Rates:

Trends and Correlates

Trends in Vaccine Use The three national surveys HHS has used to monitor changes in

immunization rates—USIS, BRFSS, and NHIS—are the sources of data used in

figures 2.1 and 2.2 to portray trends in pneumococcal and influenza

vaccine use.4

3

Medicare claims data are incomplete for the following reasons: (1) about 5 percent of the elderly are

not enrolled in Medicare, (2) as of 1991, approximately 7 percent of Medicare beneficiaries were

enrolled in prepayment plans (such as HMOs), and HCFA does not have records on the services

utilized by enrollees of these plans, and (3) the data for each calendar year are collected from claims

processed through March 31 of the following year, and HCFA estimates that up to 8 percent of

potential claims are processed after March 31. Reflecting these gaps, HCFA has estimated that

10-20 percent of Medicare beneficiaries got flu shots in 1993 that were not reimbursed by HCFA (i.e.,

for which no Medicare claim was submitted).

4

Because BRFSS data are not strictly generalizable to the U.S. population, the immunization rates for

1987 are not strictly comparable to those for earlier and later years. The 1993 data in figures 2.1 and 2.2

represent findings from the NHIS, which were in close agreement with those from the 1993 BRFSS.

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Figure 2.1: Influenza Vaccination Rates for Persons Age 65 and Oldera

Percent vaccinated

0

10

20

30

40

50

60

70

80

90

100

1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993

Year

Year 2000 goal, noninstitutionalized elderly

aImmunization rates were not estimated in 1986, 1988, 1990, and 1992. As shown, the year 2000

goal for noninstitutionalized elderly is 60 percent.

Taken together, these data suggest that annual use of influenza vaccine

and cumulative use of pneumococcal vaccine more than doubled in the

decade preceding 1993. Annual influenza vaccine use among the elderly

has increased from about 20 percent in 1964 (not shown in figure 2.1) to

about 51 percent in 1993. After a period of relative stability throughout

most of the 1980s, influenza vaccine use increased approximately

10 percentage points from 1989 to 1991 and 10 more percentage points

from 1991 to 1993. Cumulative pneumococcal vaccine use was about

11 percent in 1985 and had grown to about 27 percent in 1993.

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Figure 2.2: Cumulative Pneumococcal Vaccination Rates for Persons Age 65 and Oldera

Percent vaccinated

0

10

20

30

40

50

60

70

80

90

100

1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993

Year

Year 2000 goal, noninstitutionalized elderly

aPneumococcal vaccine became a Medicare-covered benefit in July 1981. The pneumococcal

immunization rate was not estimated in 1981-84, 1986-88, 1990, and 1992. As shown, the year

2000 goal for noninstitutionalized elderly is 60 percent.

Vaccine Use Among

Elderly Persons With

High-Risk Conditions

For all years before and including 1985 (except 1976, the year the swine flu

epidemic was expected), the rate of influenza immunization among the

high-risk elderly remained below 30 percent. By 1991, this rate had

increased to 46 percent for persons with cardiovascular disease and

52 percent for persons with pulmonary disease. In 1991, the cumulative

pneumococcal immunization rate was 21 percent for persons with

cardiovascular disease and 32 percent for persons with pulmonary

disease. (CDC analyses of 1993 NHIS data had not been completed at the

time this report was prepared.)

Characteristics of

Immunized and

Nonimmunized Persons

We identified three analyses of the characteristics of immunized and

nonimmunized persons: (1) CDC’s study of trends in influenza vaccine

coverage using USIS data collected from 1969 to 1985, (2) an investigation

of the utilization of pneumococcal vaccine among elderly Medicare

beneficiaries from 1985 to 1988, and (3) CDC’s analysis of pneumococcal

Page 21 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
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and influenza immunization status using 1989 and 1991 NHIS data.5 We

concentrated our discussion on CDC’s analyses of 1989 and 1991 NHIS data

because they provided the most current and methodologically rigorous

investigation of elderly persons’ pneumococcal and influenza vaccine use

that was available during our review.

CDC staff examined immunization rates among persons with various

demographic characteristics, health status indicators, and measures of

health behavior. (See table 2.2.) They found that, in 1991, pneumococcal

and influenza immunization rates for all subgroups in the elderly

population were well below HHS’ goal of 60-percent immunization among

noninstitutionalized elderly persons.

Table 2.2: 1991 Immunization Rates by

Demographic and Health

Characteristics of Vaccineesa

Immunization rate

Variable Pneumococcal Influenza

Demographic characteristic

Gender

Male 19.9% 41.2%

Female 20.0 40.7

Race

Black 13.4 26.5

White 20.6 42.4

Asian 14.3 28.4

Other 19.9 36.8

Poverty status

Below poverty index 15.8 35.5

Above poverty index 21.0 42.1

Education

Less than high school 17.2 36.0

High school or more 21.8 44.2

Region

Northeast 16.8 36.5

South 19.4 40.6

Midwest 20.0 42.7

(continued)

5

(1) Information supplied by CDC/NIP; (2) A. Marshall McBean, J. Daniel Babish, and Ronald Prihoda,

“The Utilization of Pneumococcal Polysaccharide Vaccine Among Elderly Medicare Beneficiaries, 1985

Through 1988,” Archives of Internal Medicine, 151 (Oct. 1991):2009-16; and (3) Desiree Rodgers et al.,

Division of Immunization, CDC and NCHS, “Results of the 1989 National Health Interview Survey” and

K.S. Heath et al., “Influenza and Pneumococcal Vaccination Among Older Adults: Results of the 1991

National Health Interview Survey [Abstract],” in Program and Abstracts of the CDC Epidemic

Intelligence Service 43rd Annual Conference (Atlanta: CDC, 1994), p. 33.

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Immunization rate

Variable Pneumococcal Influenza

West 24.6 44.4

Residential setting

Urban 21.2 40.3

Suburban 21.5 41.0

Rural 20.8 44.3

Health status

Self-reported health assessment

Fair or poor 23.0 42.8

Very good or good 19.9 42.4

Excellent 15.0 32.6

High-risk condition

Cardiovascular 21.0 46.0

Pulmonary 32.0 52.0

Activity limitations

Some 24.2 44.4

None 17.4 38.9

Health behavior

Doctor visits in past year

Zero 8.3 17.1

One 16.5 35.1

Two to four 20.7 43.5

Five or more 25.4 50.1

aFor U.S. noninstitutionalized population age 65 years and older. Immunization rates for those

under 65 years are 5.4 percent (pneumococcal) and 7.9 percent (influenza).

Source: 1991 NHIS Immunization Supplement and CDC analyses.

At the time of our review, CDC staff had completed multivariate analyses

using 1989 NHIS data only. They developed two logistic regression models,

one predicting pneumococcal vaccine use and the other predicting

influenza vaccine use. Of all the variables listed in table 2.2, those that

were significantly related to vaccination status were included in the

regression models (only region and residential setting were thus

excluded.)6

 Results from these analyses are summarized below. All

findings pertain only to the U.S. population of noninstitutionalized persons

6

In contrast, CDC’s earlier analyses of USIS data indicated that from 1973 to 1985, among all adults,

rural dwellers had higher influenza vaccination coverage than their urban counterparts. However, the

possible reasons for this apparent difference are unclear because age, race, income, education, and

use of medical care are not included in the analyses.

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65 years old or older, and all relationships are adjusted for other variables

in the model. (See table 2.3.)

Table 2.3: Logistic Regression

Predicting Pneumococcal and

Influenza Vaccination Among Persons

Age 65 and Oldera

Odds ratio

Variable Referent group

Variable

category Pneumococcus Influenza

Race Black White 2.67 2.06

Education Less than high

school

More than high

school Not significant

1.36

Health status Excellent Poor 1.77 1.36

Cardiovascular

condition None Some 1.6

Not

significant

Pulmonary

condition None Some 2.5 1.9

Activity

limitations None Some Not significant 1.23

Doctor visits None Three or more 4.14 4.35

aUsing 1989 NHIS data.

Source: CDC/NIP, 1994.

Demographic Characteristics Even controlling for education, income, health status, and use of medical

care, elderly persons who were white had almost three times the odds of

receiving pneumococcal vaccine and twice the odds of receiving influenza

vaccine as elderly persons who were black. Although having attained at

least a high school education was not significantly related to receiving

pneumococcal vaccine, it was associated with slightly higher odds of

receiving influenza vaccine. CDC found that when all other variables were

controlled, poverty and gender were not related to vaccination status, so

they were consequently dropped from the model reported in table 2.3.

These analyses did not address differences in immunization rates among

various elderly age groups.7

Health Status In general, lower health status is related to higher odds of being

vaccinated. Elderly people who reported their overall health as poor had

about 1.8 times the odds of receiving pneumococcal vaccine and about 1.4

times the odds of receiving influenza vaccine as those who described their

health as excellent. Elderly persons with a pulmonary condition had 2.5

times the odds, and those with a cardiovascular condition had 1.6 times

the odds of receiving pneumococcal vaccine, as compared to those

7

In the previously cited study of pneumococcal vaccine use based on claims among Medicare

beneficiaries between 1985 and 1988, findings indicated that persons 85 and older and those between

65 and 69 are somewhat less likely to get vaccinated than the remainder of elderly persons.

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without these high-risk conditions. Similarly, those with a pulmonary

condition had almost twice the odds, and those with activity limitations

had 1.2 times the odds of receiving influenza vaccine, as compared to

those without lung disease or activity limitations, respectively.

However, we note that CDC also found that older people with

cardiovascular disease (the leading cause of death in the United States)

were not significantly more likely to receive influenza vaccine than

persons without cardiovascular disease. This finding is important because

elderly persons with such conditions are at greater risk of dying from

pneumococcal disease and influenza.

Physician Contacts and Health

Behavior

The frequency of seeing a doctor is by far the best predictor of

pneumococcal and influenza vaccination status. Compared to elderly

persons who had not seen a doctor during the previous year, those with

three or more doctor visits had at least four times the odds of getting

vaccinated. Nonetheless, even among persons with five or more doctor

visits in the past year, half reported no influenza vaccination and three

quarters reported no pneumococcal vaccination.8

In a published report of multivariate analyses of 1987 BRFSS data, CDC also

found that such health risk-taking behaviors as smoking, obesity, lack of

seat-belt use, and sedentary lifestyle are related to decreased likelihood of

influenza vaccine use.9

Summary HHS relies principally on the National Health Interview Survey for tracking

trends in immunization rates. This strategy has some disadvantages, but

currently provides the best available information on pneumococcal and

influenza immunization rates. Importantly, more than a decade after

Congress made pneumococcal vaccination almost universally available to

elderly persons through Medicare coverage, survey data indicate that

about 73 percent of older Americans have not received this one-time-only

vaccination. Moreover, in the 1993 flu season, just before Medicare began

coverage of flu shots, 49 percent of elderly Americans had not been

vaccinated against influenza. HHS officials report that preliminary data

from a survey of beneficiaries conducted for the 1993-94 flu season found

8

In chap. 4, we discuss the significance of recommendations by physicians, and in chap. 5, we discuss

hospital-based immunization strategies.

9

Paul A. Stehr-Green et al., “Predictors of Vaccination Behavior Among Persons Ages 65 Years and

Older,” American Journal of Public Health, 80:9 (Sept. 1990), 1127-29.

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a higher rate of flu vaccine use (60.8 percent), but roughly the same low

level of use for pneumococcal vaccine (28 percent).10

Among elderly persons with high-risk conditions, immunization rates tend

to be higher, but they are still below HHS goals set as long ago as 1980. In

1991, surveys indicated 21 percent of persons with heart disease and

32 percent of those with lung disease had received pneumococcal

vaccination, while 46 percent of persons with heart disease and 52 percent

of those with lung disease had received influenza vaccination.

According to CDC’s analyses of 1989 NHIS data, although all major

subgroups of the U.S. elderly population are undervaccinated, some are

less likely to get vaccinated than others. Two such cases stand out. First,

elderly persons who are black are two to nearly three times less likely to

receive pneumococcal and influenza vaccines than elderly persons who

are white, even after adjusting for other factors. Second, elderly people

with no doctor visits in the previous year are over four times less likely to

receive these vaccinations than those who have visited a physician three

or more times. Even so, 75 percent of elderly persons with five or more

physician visits report failing to receive pneumococcal vaccination.

Persons who reported poor health status or lung conditions were more

likely than persons without these conditions to be immunized for flu or

pneumococcal disease. However, CDC’s analyses show that elderly persons

with a cardiovascular condition are no more likely to receive influenza

vaccine than those without a cardiovascular condition.

10We did not independently examine the methodology of this survey, the response rate, or the

precision of the estimate. It is not strictly comparable to earlier surveys, which used a broader

sampling frame and different methods for obtaining data.

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Agency Immunization Strategies

In this chapter, we describe HHS activities undertaken to increase

pneumococcal and influenza immunization in the respective periods since

these vaccines became Medicare benefits. We also provide information on

the resources that major departmental units have applied to improving

these immunization rates.

Activities to Improve

Immunization Rates

Health Care Financing

Administration

Since pneumococcal vaccination became a Medicare-covered service over

13 years ago, HCFA has made only a few attempts to encourage the use of

this vaccine among the elderly. HCFA announced the availability of the

pneumococcal vaccine benefit in Medicare carrier and intermediary

manuals, but did not require carriers and intermediaries to inform

providers of the new benefit. To inform beneficiaries of the new benefit,

HCFA has included brief statements in Medicare handbooks, Social Security

check inserts sent to beneficiaries in January 1982, and flu vaccine

promotional flyers produced and distributed during its fiscal year 1994

campaign.

HCFA’s promotion of influenza vaccination since it became a

Medicare-covered benefit in 1993 consists of four major activities:

(1) requiring that carriers and intermediaries notify physicians, providers,

and suppliers of Medicare coverage of the influenza vaccine and its

administration; (2) simplifying certain billing procedures; (3) conducting a

public information effort in fiscal year 1994 known as the Medicare Flu

Shot Campaign; and (4) implementing a targeted public information effort

and supplementary activities known collectively as the Consumer

Information Strategy in fiscal year 1995. Each of these activities is

explained more fully below.

In July 1993, HCFA instructed its carriers and intermediaries to notify

physicians, providers, and suppliers of the new influenza vaccine benefit.

HCFA did not specifically evaluate compliance with this routine request;

however, judging from the activities of a nonrepresentative sample of 11

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Agency Immunization Strategies

carriers and intermediaries summarized by HCFA, the form of this

notification effort varied widely.1

To remove inconveniences to providers claiming reimbursement for

immunization services, HCFA began to allow those public health centers

that do not use electronic billing systems to submit a “roster” of vaccinees

rather than bill for each beneficiary separately. HCFA also permitted

providers or suppliers to bill separately for vaccine or vaccine

administration, rather than require that both claims be submitted together.

This policy change responds to situations in which providers receive free

vaccine (from states or organizations) and need to bill only for its

administration.

HCFA’s Office of Public Affairs coordinated the HHS fiscal year 1994

Medicare Flu Shot Campaign with staff from PHS and the Administration on

Aging. A number of activities were conducted as part of this campaign,

including a press conference by the Secretary; incorporation of brief

announcements in Medicare claims forms sent to beneficiaries who had

had claims (see appendix III); and distribution of public service

announcements, video and audio news releases, op-ed pieces, flyers, and

supermarket displays. According to information provided by HCFA’s Office

of Public Affairs, by December 1993, 8 percent of the nation’s newspaper

and radio stations and 28 percent of television stations had aired HHS flu

benefit information.

The fiscal 1995 Medicare Flu Shot Campaign—which HCFA describes as the

first initiative in its new Consumer Information Strategy—built on the

public information strategy of the fiscal 1994 campaign. Data

dissemination, another component of the 1995 strategy, entails making

available to consumers and providers claim-based calculations of states’

and counties’ flu immunization rates tabulated by age, gender, and race.

Finally, a local intervention component of the 1995 strategy consists of

peer review organizations’ and carriers’ collaboration with local health

care organizations in seven geographic areas to increase immunization

rates in their parts of the country. The agency also reported it was

considering increasing the vaccine administration fee ($3.71, regionally

then adjusted) and simplifying billing procedures for institutions.

1

Some carriers and intermediaries announced the flu benefit in provider bulletins, some sent letters to

public health centers, and some also sponsored clinics or seminars, usually at health fairs or

conferences, at which they distributed information on influenza immunization to providers or

beneficiaries. The number of persons contacted was typically in the hundreds. At the extreme, one

carrier reported that it mailed 275,000 flyers to seniors in Florida.

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National Vaccine Program

Office

In its role as coordinator of immunization activities across the federal

government, NVPO has developed the National Vaccine Plan, which defines

the PHS strategic framework for fiscal years 1994 and 1995. The major goals

cited in this document include better educating the public and members of

the health professions on the benefits and risks of immunization and

achieving better use of existing vaccines to prevent disease, disability, and

death. The Plan observes that vaccination coverage in adults over 65 years

of age is low, cites estimates of the cost of vaccine-preventable diseases

exceeding $10 billion each year, and acknowledges that over 27,400 deaths

per year are preventable through increased use of influenza and

pneumococcal vaccines.2

 However, even though the National Vaccine Plan

adopts the objective of increasing “immunization coverage levels among

older adolescents, adults, and the elderly,” efforts to improve childhood

immunization constitute its top priority.

The fiscal 1994-95 National Vaccine Plan states that the “NVPO with other

agencies will identify steps that federal agencies can take to implement the

National Advisory Committee report on ’Adult Immunization.’”3

 However,

the plan does not state what level of priority or resources might be

accorded such steps.

Centers for Disease

Control and Prevention

CDC’s activities for increasing the use of flu and pneumococcal vaccines

are concentrated in the National Immunization Program, which in 1994

dedicated 5 of its 289 full-time staff to the agency’s Adult Immunization

Initiative.4

 Since late 1994, the number of NIP staff working directly on

adult immunization issues has increased to seven. These staff have

provided information and educational materials to professional and lay

groups by publishing articles on pneumococcal and influenza

immunization in professional journals and participating in CDC-supported

forums, conferences, and presentations on related immunization topics. In

2

Pierce Gardner and William Schaffner, “Immunization of Adults,” New England Journal of Medicine,

328:17 (Apr. 29, 1993), 1252-58.

3

(1) NVPO, Disease Prevention Through Vaccine Development and Immunization: The National

Vaccine Plan (Washington, D.C.: PHS 1994), p. vii; and (2) National Vaccine Advisory Committee, Adult

Immunization (Washington, D.C.: PHS, Jan. 1994).

4

Epidemiologic and laboratory research on pneumonia and influenza is conducted at CDC’s National

Center for Infectious Diseases. According to officials there, staff from the viral and bacterial branches

dedicate the equivalent of about one full-time staff per year to answer telephone calls about

pneumonia and influenza from the public, health care providers, and the media. NCID’s Influenza

Branch of the Division of Viral and Rickettsial Diseases monitors influenza strains and conducts

research on vaccine development, evolution of flu strains, and viral resistance to amantadine (an oral

drug that reduces influenza A symptoms). The Division of Bacterial and Mycotic Diseases investigates

the epidemiology of pneumococcal disease and conducts research on pneumococcal vaccine efficacy,

diagnostic tests for pneumococcal disease, and antibiotic resistance of pneumococci.

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addition to these general informational activities, CDC has printed and

distributed an adult immunization pamphlet, a promotional kit, and a

guidebook on managing influenza vaccination programs in nursing homes.

CDC has also collaborated with HCFA on major research and demonstration

projects related to pneumococcal and influenza vaccination, such as the

Hawaii Pneumococcal Disease Initiative (Feb. 1988-Feb. 1989) and the

Medicare Influenza Demonstration (fiscal years 1989-92). Finally, the

agency is responsible for vaccination recommendations, guidelines, and

standards for immunization.

CDC has not used its grant support of state and metropolitan immunization

projects to mount a broad effort to increase pneumococcal and influenza

immunization rates, citing the emphasis on childhood immunization

responsibilities in fiscal 1990-95 legislative documents. CDC and NVPO

officials indicated that expenditure of further resources on activities to

improve pneumococcal and influenza immunization rates would have been

inconsistent with congressional guidance.

National Institute on Aging In 1993, NIA initiated a provider-focused informational campaign to

encourage pneumococcal vaccine use. NIA consulted infectious disease

experts, conducted a literature review, and ran focus groups with

physicians and elderly persons to identify barriers to higher immunization

rates. Subsequently, NIA held a conference with members of health care

specialty groups and, in spring 1994, mailed 120,000 informational kits to

members of six medical associations.

Office of Disease

Prevention and Health

Promotion

In early fall 1994, PHS’ Office of Disease Prevention and Health Promotion

launched a national effort to improve the delivery of preventive services in

primary care settings. This initiative, called “Put Prevention Into Practice,”

makes materials available for sale to providers, patients, and professional

organizations that are based on tested interventions. They include aids in

flagging the charts of patients for whom various preventive interventions

are indicated and forms for improving provider and patient records of

preventive services.5

 Pneumococcal and influenza vaccination feature

prominently in these materials, and assuming they are widely used, they

appear promising for improving vaccination levels.

5

HHS/PHS, “Put Prevention Into Practice” Education and Action Kit, GPO Stock Number

017-001-00492-8 (Pittsburgh: Government Printing Office, 1994).

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Resources

Health Care Financing

Administration

Medicare expenditures for fiscal year 1994 included about $100 million for

influenza and pneumococcal vaccine and vaccine administration. HCFA

spent about $95,000 conducting the fiscal 1994 Medicare Flu Campaign.

National Vaccine Program

Office

National Vaccine Program funding began in fiscal year 1988. In fiscal years

1992 and earlier, the budget included both discretionary and NVPO

operation expense funds, and during this time, the vast majority of

program funds were dedicated to discretionary spending.6

 These

discretionary funds were distributed to three PHS agencies (CDC, Food and

Drug Administration, and National Institutes of Health) for emerging

high-priority vaccine projects.7

 In fiscal year 1993, the total National

Vaccine Program budget declined sharply; the operating budget was

actually higher than in previous years, but none of the discretionary

spending in fiscal years 1993 and 1994 was administered by NVPO. Under

fiscal year 1995 appropriations, staffing and resource allocations for the

NVPO have been substantially reduced.

Centers for Disease

Control and Prevention

According to the Director of the National Immunization Program at CDC,

adult immunization is a “top, but unfunded, priority.” In making this

statement, the Director relies on language in the House Appropriations

Committee report on the PHS appropriation for fiscal 1994. In the report,

the Committee emphasizes childhood immunization. However, we found

that the law permits CDC to increase its spending on pneumococcal and

influenza immunization activities, and these activities are, of course,

consistent with its public health mission. But CDC believes that an increase

in resources for these activities would be inconsistent with the priority the

Committee has given to childhood immunization.

CDC’s congressional appropriations for immunization activities increased

more than sixfold between fiscal years 1987 and 1994, with a 55-percent

increase in 1994 over the previous year. CDC distributed 94 percent of its

6

The highest priority for these funds was to accelerate the development of a new whooping cough

vaccine. Other high-priority areas for discretionary spending were measles vaccine, vaccine safety and

adverse events, the Children’s Vaccine Initiative, the Sexually-Transmitted Disease Initiative, and

research on development of a new influenza vaccine.

7

These discretionary funds are also described as seed money “to nurture promising vaccine initiatives

and encourage the development of new and innovative ideas to improve vaccine development and

delivery.”

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$528 million fiscal year 1994 immunization budget to NIP, but less than 1

percent (less than $1 million) was dedicated to adult immunization

activities.

The majority of CDC’s immunization funds—$423 million in fiscal year

1994—are distributed to public health agencies throughout the country in

Immunization Program Grants. Although the promotion of adult

immunization is one of the grant program’s eight goals and CDC

recommends these activities, they have not been among the 26

requirements that potential grantees must meet.

Like its budget, CDC’s staff positions for immunization activities have also

increased substantially, having more than doubled (from 125 to 289

full-time equivalents) between 1987 and 1994. However, the number of

staff positions dedicated to adult immunization activities—five—remained

constant during this period, increasing to seven in late 1994.

Summary In the 1993-94 flu season, HHS conducted varied activities to increase flu

immunization rates and inform Medicare beneficiaries of the new coverage

for flu immunization. Specifically, HHS published research articles,

conducted public information campaigns, distributed informational kits

and pamphlets, held immunization conferences, and asked Medicare

carriers and intermediaries to inform providers of the new flu benefit. In

the present flu season, HCFA has augmented these strategies with the

dissemination of data on state and county flu immunization rates, and PHS

has developed materials to assist providers and consumers in recording

and implementing preventive services.

In contrast, from 1981 until 1993, HHS did little apart from routine carrier

notification to inform providers of Medicare coverage for pneumococcal

immunization. Moreover, the Department did little during this period to

educate beneficiaries of vaccine availability, apart from briefly announcing

vaccine availability in Medicare Handbooks and a 1982 Social Security

check insert.8

 Supplementing these efforts, NIA has conducted activities to

educate health care providers on the vaccine and its indications by

sending printed material to members of several medical associations. PHS

recently launched its “Put Prevention Into Practice” initiative, which will

publish potentially effective materials on the vaccine, but providers must

purchase these materials.

8

HHS officials believe, and we agree, that Social Security check inserts are costly and would not reach

the large portions of beneficiaries who use direct deposit.

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Among the agencies we reviewed, the bulk of expenditures related to

influenza and pneumococcal immunization were made by HCFA in the form

of reimbursements to providers for immunization services. We found that

only modest sums were spent on supplementary activities to promote use

of these benefits. NVPO and CDC clearly acknowledge the scope of the

public health problem associated with influenza and pneumococcal

disease, but HHS refers to language in the legislative history of fiscal

1990-95 appropriations in explaining PHS’ low expenditures on activities

related to improving these immunization rates. We reviewed the record of

appropriations hearings and found that HHS has not taken a leadership role

in defining pneumococcal and influenza immunization as critical public

health issues for the Congress.

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This chapter discusses what is known from HHS analyses, and from the

literature more generally, about potential reasons for the low levels of

adult immunization against pneumococcal disease and influenza. Although

the data are limited, they suggest both reasons for the current rates and

ways to increase them. Below, we distinguish between explanations linked

to consumer behavior and explanations based on provider behavior.

Influences on Vaccine

Consumers’ Behavior

Among the factors that may explain consumers’ low demand for

pneumococcal and influenza vaccination are their awareness of vaccine

availability; attitudes about disease susceptibility and severity; and

concerns about vaccine side effects, safety, and efficacy. In appendix I, we

briefly describe the information HHS has collected on influences on

consumer behavior that may have led to low immunization rates and note

the limitations of these data.

Recent evidence indicates that consumers lack awareness of

pneumococcal vaccine. For influenza vaccine, we found that consumers

reported misconceptions about vaccine efficacy and safety, disease

severity, and their own susceptibility to the disease. These factors may

help explain low immunization rates, but it is not clear how much of an

impact on those rates can be achieved by addressing these factors alone.

Awareness of Vaccine

Availability

A Gallup poll conducted in the fall of 1993 found that only 25 percent of all

adults 55 years old or older were aware that a safe, effective

pneumococcal vaccine exists.1

 However, a high level of vaccine awareness

does not necessarily ensure high vaccination rates: a 1987 CDC study of

elderly residents in two Georgia counties found that 90 percent were

aware of the flu vaccine, yet only 55 percent said they had received it

within the past year.2

Beliefs About

Susceptibility to Disease

Consumers are probably more likely to seek a particular preventive

service if they believe they may be susceptible to the disease it prevents.

National surveys conducted in 1977-78 by Opinion Research Corporation

(ORC) indicate that adults of all ages tended to see themselves as more

1

Voluntary Hospitals of America/Gallup Poll, fall 1993.

2

This vaccination rate is more than 20 percentage points higher than the 1987 national rate for elderly

people, but the sample is representative only of certain counties in Georgia.

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susceptible to influenza than to any other vaccine-preventable disease.3

Nonetheless, survey data from persons who did not receive immunization

in the recent Medicare Influenza Demonstration revealed that the most

common reason for not getting the flu vaccine was the belief that one was

healthy and did not need it. (See appendix I, table I.2.)

Data on beliefs about susceptibility to pneumonia are more sparse.

However, almost 70 percent of elderly Hawaiians who responded to a 1988

survey recognized that pneumonia is a more common cause of illness in

people over 65 than in younger people.

Beliefs About Disease

Severity

Research also suggests that consumers may be more likely to seek a

preventive service if they view the disease it prevents as a serious matter.

With respect to flu, the ORC survey found that adults of all ages tended to

perceive influenza as the least serious vaccine-preventable disease of

adulthood. Survey data from the 1988 Hawaii Pneumococcal Disease

Initiative indicated that 78 percent of elderly respondents viewed

pneumonia as a serious disease, and 57 percent viewed influenza as a

serious disease. According to CDC, influenza-attributable death is

90 percent higher than reported in current vital statistics (that is, nearly

twice as high as current reports).

Beliefs About Vaccine Side

Effects, Safety, and

Efficacy

Concerns about vaccine side effects, safety, and efficacy were frequently

cited reasons for not receiving influenza vaccination by elderly residents

of the 10 communities that participated in the Medicare Influenza

Demonstration. (See appendix I, table I.2.) Similarly, CDC’s 1987 survey in

Georgia found that 73 percent of respondents who were aware of the flu

vaccine believed that it caused illness, did not protect against influenza, or

was unnecessary.4

 Of those who were aware of the pneumococcal vaccine,

36 percent believed that it would not prevent pneumonia or would make

them sick.

3

Pneumonia was not included in the list of diseases that respondents considered.

4

This includes many people who received the vaccine, since 55 percent of respondents reported having

been immunized. However, as we note in chap. 5, beliefs may be a less important influence than the

behavior of providers on the elderly’s receipt of immunization.

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Negative attitudes lingering from the 1976 swine flu vaccine initiative may

color current perceptions about flu shots in general.5

 When respondents

were asked in a 1977 ORC survey whether there are “any specific

vaccinations . . . which you feel are unsafe,” fully 78 percent of those who

said “yes” mentioned “swine flu,” whereas only 11 percent said “flu”

without mentioning a specific type. Six months later, 59 percent

mentioned “swine flu” and fully 30 percent mentioned “flu” without

indicating a specific type.

Negative perceptions about the flu vaccine may also be related to

misconceptions about its efficacy. In NIA’s focus groups with elderly

adults, most participants reported having had a negative experience with

the flu vaccine or said they knew someone who had. Although a flu-like,

winter respiratory illness may be coincident to, rather than caused by,

influenza vaccination, people may conclude that the flu vaccine either

failed to work or, worse, induced the illness.6

Influences on

Providers’ Behavior

In this section, we examine potential explanations of low pneumococcal

and influenza immunization rates that focus on providers’ knowledge or

behavior. Evidence suggests that physician recommendation is a strong

motivator to accept vaccination, regardless of patient attitudes. Thus, we

consider physicians’ knowledge, attitudes, and practices, as well as

institutional practices within hospitals, health maintenance organizations,

and nursing homes. We find evidence that suggests missed opportunities

to offer vaccine to elderly persons in physicians’ practices and

institutional contexts and failure in many cases to maintain immunization

records. In appendix II, we briefly describe the information HHS has

5

In Feb. 1976, an influenza virus was isolated that was antigenically similar to the virus implicated in

the 1918 influenza pandemic, which took over 500,000 lives in the United States alone. The federal

government initiated a massive immunization program, and between Oct. 1, 1976, and Dec. 16, 1976,

nearly 43 million doses of swine flu vaccine (influenza A/New Jersey/1976) were administered.

However, the program was stopped when an increasing number of reports of vaccine-related

Guillain-Barré Syndrome were reported. This is a neurologic condition that is associated with a variety

of viral, bacterial, and other infections; toxins and drugs; disorders of various kinds; and some

vaccines. By Jan. 10, 1977, 581 cases had been reported, of which 295 had received the swine flu

vaccine. Researchers found that the relative risk of Guillain-Barré syndrome in influenza-vaccinated

persons was 8.8 times greater than in unvaccinated persons. (See Schonberger et al., “Guillain-Barré

Syndrome Following Vaccination in the National Immunization Program, United States, 1976-77,”

American Journal of Epidemiology, 110 (1979), 105-23.)

6

In its 1986 monograph entitled New Vaccine Development: Establishing Priorities, the Institute of

Medicine discusses “the mistaken concept that influenza vaccines should prevent all winter respiratory

tract illnesses. Any acute illness that is experienced in the winter following receipt of an influenza

vaccine may be attributed [erroneously] to vaccine failure. In fact, there are other acute virus

infections that cause illness in all members of the community, including those vaccinated against

influenza.”

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collected on provider-based factors that have been linked to low

immunization rates and note the limitations of these data.

Physician Knowledge and

Attitudes

The available literature suggests that most primary care physicians know

about the seriousness of pneumococcal and influenza disease and that half

or more of these providers are familiar with the recommendations for

vaccination. Moreover, most tend to have favorable attitudes about

vaccine safety and efficacy, though some doubts about vaccine efficacy

linger among a minority of physicians. For example, in 1980, CDC found

that about 90 percent of primary care physicians were aware and

supportive of flu vaccination recommendations for the elderly.7

 Fewer

physicians knew the indications for pneumococcal vaccination. However,

two-thirds of general and family practitioner respondents and just over

one-half of responding internists believed that elderly people should get

pneumococcal vaccination. CDC also found that most primary care

physicians (over 70 percent) believed that influenza vaccine is very safe,

and that it is effective for at least 60 percent of patients. Fewer than

10 percent expressed concerns about pneumococcal vaccine safety or

effectiveness.

These findings are consistent with more recent results from focus groups

run by the National Institute on Aging in 1993 and findings from the 1988

Hawaii Pneumococcal Disease Initiative, which found that among the

35 percent of physicians responding to a survey, roughly half recognized

age over 65 as an indication for flu and pneumococcal immunization. HHS

officials commenting on this report noted a continuing need for provider

education, but agreed with our conclusion that physicians’ vaccination

practices should be the major focus of attention.

Medical education in adult immunization and vaccine-preventable disease

is brief but widespread. In a 1991 survey of U.S. medical schools and

primary care residency programs, CDC found that almost 90 percent of

medical schools reported teaching about influenza, spending an average of

30 minutes to 1 hour on the subject. In addition, about one-third of internal

medicine residency programs reported teaching about vaccine-preventable

disease in adults, prevention of these diseases, and vaccination

indications. Although HHS officials argued that current instructional

practices are insufficient, it remains unclear whether or to what extent

7

Market Facts, “Attitudes and Practices of Private Physicians Related to Influenza and Pneumococcal

Immunization, 1980, Volume I.” Final report submitted to CDC, Jan. 30, 1981.

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enhancement of routine medical instruction would affect provider

practices.8

Physician Practices

Recommendations to Patients The significance of a physician’s vaccination recommendation has been

clearly demonstrated. Its absence acts as a barrier to vaccine receipt; its

presence is a motivator to get vaccinated. Figure 4.1 shows the

relationship between physician recommendations and the immunization

rates for patients with positive and negative attitudes toward vaccination.

Most surveyed physicians report that they recommend vaccination to their

patients for whom it is indicated (i.e., elderly persons and those with

high-risk conditions). Evidence shows, however, that neither physicians’

knowledge nor their self-reported implementation of vaccination

recommendations is a reliable predictor of their actual immunization

practices. For example, although almost all primary care physicians

surveyed by ORC in 1980 believed and recommended that high-risk patients

should be vaccinated and reported recommending the flu vaccine to their

high-risk patients, they reported vaccinating only about one-half of these

patients, on average, and only about one-third of their non-high-risk

elderly patients. An unknown number of patients may have refused their

physician’s recommendation.

Stronger evidence of a discrepancy between physicians’ immunization

knowledge or attitudes and their practices comes from a study conducted

at a primary care clinic in Milwaukee in the mid-1980s.9

 Of the 92

physicians practicing at this clinic, over 75 percent knew flu vaccine

recommendations, contraindications, and objectives, and two-thirds

believed the vaccine was between 70- and 90-percent effective. Yet when

medical records were examined from 3 peak months of the 1984-85 flu

season, only 41 percent of these physicians’ eligible patients had been

offered vaccine. Rates of offering vaccine varied widely across physicians,

8

A Minnesota study on influenza immunization in hospital settings recently compared the effect of

physician education to that of physician reminders and standing orders for immunization by a nurse. It

found that education was the least effective of the three approaches, both in terms of the percentage

of patients offered vaccine and the percentage who received it. See R.J. Krouse et al., “Hospital-Based

Strategies for Improving Influenza Vaccination Rates,” Journal of Family Practice, 38 (Mar. 1994),

258-61.

9

Paul W. McKinney and Gary P. Barnas, “Influenza Immunization in the Elderly: Knowledge and

Attitudes Do Not Explain Physician Behavior,” American Journal of Public Health, 79:10 (Oct. 1989),

1422-24.

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from zero to 90 percent, with vaccination refused by only 9 percent of

those to whom it was offered.

Figure 4.1: Relationship Between

Physician Recommendation and

Immunization Rates

Percent vaccinated

0

10

20

30

40

50

60

70

80

90

100

Georgia:

Influenza

Georgia:

Pneumococcal

Hawaii:

Influenza

Dr. recommendation/positive patient attitude

Dr. recommendation/negative patient attitude

No recommendation/positive patient attitude

No recommendation/negative patient attitude

Source: “Adult Immunization: Knowledge, Attitudes, and Practices - DeKalb and Fulton Counties,

Georgia, 1988,” Morbidity and Mortality Weekly Report, CDC, 37:4 (Nov. 4, 1988), 657-61; and

Walter W. Williams, “Hawaii Pneumococcal Disease Initiative: Surveys of Consumer and Physician

Knowledge, Attitudes, and Practices,” 26th National Immunization Conference Proceedings, St.

Louis, June 1-6, 1992.

Record-Keeping Maintaining an immunization record is a basic aspect of providing

vaccine-related care. However, only 42 percent of internists surveyed in

1987 by the American College of Physicians reported maintaining

immunization data for their patients. Among the types of preventive and

diagnostic data covered by the survey, immunization status was among the

least frequently recorded, outranking only information on sexual activities

and seat-belt use.

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Interestingly, most of the internist participants in NIA’s focus groups

mentioned forgetting as an important reason why they had not

administered the pneumococcal vaccine to more patients. Physicians

explained that patients usually are in the office for other reasons, and

vaccination is relatively low on their list of priorities.10

Another factor that apparently contributes to suboptimal immunization

practices is that, according to a 1988 CDC survey of all physicians

practicing in Hawaii, most of those responding did not consider

vaccination to be a part of their practice.

Institutional Practices

Hospitals Several studies have shown that hospitals admit patients at high risk of

pneumococcal and influenza disease and miss opportunities to vaccinate

them before their discharge. An analysis of the medical records of 1,633

Medicare beneficiaries in the Shenandoah region of Virginia with any type

of pneumonia admission to hospitals in 1983 showed that 62 percent of

these beneficiaries had been discharged at least once from a hospital

(often from the same hospital) in the same region in the previous 4 years.

Almost 90 percent of these patients had high-risk medical conditions listed

on their previous discharge summaries.11 Additional research, conducted

in the United States and the United Kingdom, showed that approximately

two-thirds of patients hospitalized with pneumococcal bacteremia during

the study period had been discharged at least once in the preceding 3 to 5

years.12 Similarly, a Canadian study found that although only 8 percent of

the elderly in Manitoba had been discharged from a hospital during the

1982-83 vaccination season, this group accounted for almost 45 percent of

subsequent influenza-associated hopitalizations and fully two-thirds of all

hospital deaths from influenza-associated illness. Moreover, HHS officials

reported that a survey of medical/surgical hospitals completed in 1994

found that over 60 percent of responding hospitals had no policy for

vaccinating inpatients or outpatients against pneumococcal disease or

influenza.

10Chap. 5, on effective vaccination strategies, presents strong evidence that methods of reminding

physicians to vaccinate eligible patients significantly increase vaccination rates.

11David S. Fedson, “Clinical Practice and Public Policy for Influenza and Pneumococcal Vaccination of

the Elderly,” Clinics in Geriatric Medicine, 8:1 (Feb. 1992), 183-99.

12John S. Spika, David S. Fedson, and Richard R. Facklam, “Pneumococcal Vaccination: Controversies

and Opportunities,” Infectious Disease Clinics of North America, 4:1 (Mar. 1990).

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Health Maintenance

Organizations

The Health Maintenance Organization Act of 1973 (as amended) mandates

immunizations as one of the basic services to be included in the benefits

offered by federally qualified HMOs. In 1987-88, CDC commissioned a survey

of HMOs with 25,000 members or more that had at least 3 years of

operational experience, but received responses from less than 25 percent

of them.13 Among those HMOs responding to the survey, fewer than

50 percent had written policies specifying use of vaccines for adults, fewer

than 20 percent issued an immunization record to members, high-risk

members were not consistently identified, reminder systems were

generally unavailable to physicians or members, administrative

encouragement was lacking, promotion of vaccine use was limited, and

data management systems were not adequate to monitor immunization

levels.

Nursing Homes HHS has not routinely monitored immunization rates in nursing homes.

Available data on influenza immunization in nursing homes suggest that

vaccination rates may have improved between the 1980s and 1990s, but

that they are still quite variable across facilities. In the early and

mid-1980s, findings from CDC’s studies of 67 nursing homes in six states

showed that, on average, only 55 to 65 percent of nursing home residents

were vaccinated against influenza in any given year. However, when Abt

Associates surveyed over 500 nursing homes as part of the Medicare

Influenza Demonstration from 1990 to 1992, it found higher overall

vaccination rates of about 70 percent, on average. The studies found that

having a vaccination policy, not requiring a physician’s order for

vaccination, and not requiring patient consent were associated with

slightly higher vaccination rates. CDC also found a significant difference in

vaccination rates between homes requiring consent from family members,

which had vaccinated an average of 57 percent of patients, and homes that

did not require familial consent, which had vaccinated 90 percent.

Summary We identified several factors that may help explain why pneumococcal

and influenza immunization rates are below HHS goals. We found that

consumers lack awareness of the availability of pneumococcal vaccine. In

the case of influenza vaccination, public awareness is high, but elderly

people tend to underestimate the seriousness of, and their susceptibility

to, influenza-related disease. Moreover, recent data suggest that

consumers may have exaggerated concerns about influenza vaccine side

effects, safety, and efficacy. However, it is difficult to accurately predict

13See also John P. Mullooly et al., “Influenza Vaccination Programs for Elderly Persons:

Cost-Effectiveness in a Health Maintenance Organization,” Annals of Internal Medicine, 121

(Dec. 1994), 947-52.

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the extent to which addressing attitudinal factors alone might increase

vaccination rates above current levels.

Regardless of the patient’s personal attitudes about the vaccine, a

physician’s recommendation appears to be a strong motivator for a patient

to get vaccinated. However, evidence suggests that physicians’ actual

immunization practices are often inconsistent with their intentions or

self-reported practices. Forgetting to offer vaccine and the perceived limits

or demands of a physician’s practice are more plausible explanations for

this than lack of knowledge; available evidence suggests that most

physicians know basic facts about pneumococcal and influenza disease

and that half or more are familiar with vaccine recommendations.

With respect to the role of health care organizations, limited data from the

late 1980s suggest poor immunization practices in HMOs, and data from the

mid-1980s imply uneven immunization practices in nursing homes.

Importantly, we found strong evidence of missed opportunities to offer

vaccination to high-risk patients before their discharge from hospitals.

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Promising Immunization Strategies

We identified four interventions that show some promise of increasing

pneumococcal and influenza immunization: (1) reminder contacts with

potential vaccinees, (2) physician reminder systems, (3) issuance of

standing orders in hospitals for immunizing patients before discharge, and

(4) practice-based tracking systems. Although public information

campaigns and vaccination clinics have been associated with successful

immunization efforts, their independent impact on immunization rates has

not been rigorously tested.

Reminder Contacts

With Potential

Vaccinees

Findings from controlled studies and randomized clinical trials show that

providing a reminder to potential vaccinees is an effective means of

increasing adult immunization rates.1

 Two studies have shown 100-percent

greater immunization rates among patients who are sent well-designed

postcard reminders, as compared with “neutral” postcard reminders or no

reminder. Such reminders establish direct patient contact; come from an

authoritative source; state vaccination recommendations; provide

information about disease susceptibility and risk, and about vaccine cost,

safety, and efficacy; and provide information about where to obtain

vaccination. This finding is consistent with the views of most project

coordinators from the Medicare Influenza Demonstration, who concluded

that a letter to beneficiaries from the HCFA Administrator was the most

effective immunization strategy employed. (See appendix IV.)2

Physician Reminder

Systems

The effectiveness of interventions that remind physicians to offer vaccine

supports the notion that physicians’ failure to carry out preventive health

measures results from oversight rather than intentional disregard. Several

carefully controlled studies have demonstrated that physician reminder

systems effectively increase preventive health practices in general, and

pneumococcal and influenza vaccination in particular.

One study tested the effect of incorporating an age- and gender-specific

checklist of preventive health guidelines into ambulatory care patients’

medical records. Physicians who were randomly assigned checklists had

1

See, for example, Eric B. Larson et al., “Do Postcard Reminders Improve Influenza Vaccination

Compliance? A Prospective Trial of Different Postcard ‘Cues,’” Medical Care, 20:6 (June 1982), 639-48;

Eric B. Larson et al., “The Relationship of Health Beliefs and a Postcard Reminder to Influenza

Vaccination,” Journal of Family Practice, 8:6 (1979), 1207-11; and Ronald Brimberry, “Vaccination of

High-Risk Patients for Influenza: A Comparison of Telephone and Mail Reminder Methods,” Journal of

Family Practice, 20:4 (1988), 379-400.

2

“Medicare Influenza Vaccine Cost-Savings Study: Evaluation Report” (Cambridge, Mass.: Abt

Associates, Mar. 22, 1993), p. 30.

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significantly higher compliance across a range of preventive measures,

their utilization of influenza vaccine doubled, and their utilization of

pneumococcal vaccine increased fourfold over physicians without

checklists.3

 In another study, physicians and patients were randomly

assigned to medical clinics that either did or did not append checklists of

recommended preventive guidelines to patient charts. After 4 months,

42 percent of patients seen in checklist clinics had received pneumococcal

vaccine, whereas only 5 percent of patients seen in clinics that did not use

checklists had received the vaccine during the same period. Similarly, at

the end of the intervention, 36 percent of the “checklist patients” had

received influenza vaccine, and only 4 percent of the others had.4

Other research has demonstrated the effectiveness of computer-based

physician reminder systems. In a study where medical records were

electronically stored and reminders generated for each patient, physicians

who had been reminded were twice as likely to provide influenza vaccine

and over four times as likely to provide pneumococcal vaccine to their

eligible patients, as compared to physicians who were not reminded.5

Finally, the effectiveness of another type of computer-based physician

reminder system has also been demonstrated. In this study, before a

physician could order discharge papers from a hospital’s computer, two

data screens would come up to remind the physician of pneumococcal

vaccine recommendations, ask about the patient’s immunization status,

and inquire whether the physician wished to order vaccine for the patient

before discharge. Fewer than 4 percent of eligible patients received

pneumococcal vaccine before this system was implemented, as compared

with 45 percent afterward.6

Standing Orders for

Vaccination

Another immunization strategy that lessens reliance on physician

compliance with adult immunization guidelines involves the issuance of

standing orders. Following implementation of standing orders, an urban

hospital in New York increased its pneumococcal vaccination rate from

zero to 78 percent of patients for whom the vaccine was indicated. First,

the head of the Infectious Diseases Division and the director of the

3

Carol Cheney and Joe W. Ramsdell, “Effect of Medical Records Checklists on Implementation of

Periodic Health Measures,” American Journal of Medicine, 83 (July 1987), 129-36.

4

David I. Cohen et al., “Improving Physician Compliance With Preventive Medicine Guidelines,”

Medical Care, 20:10 (Oct. 1982), 1040-45.

5

Clement J. McDonald et al., “Reminders to Physicians From an Introspective Computer Medical

Record: A Two-Year Randomized Trial,” Annals of Internal Medicine, 100:1 (Jan. 1984), 130-38.

6

Carolyn M. Clancy, Daniel Gelfman, and Roy M. Poses, “A Strategy to Improve the Utilization of

Pneumococcal Vaccine,” Journal of General Internal Medicine, 7 (Jan.-Feb. 1992), 14-18.

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medical service issued standing orders to immunize all eligible patients.

Then, a nurse was assigned to make daily rounds, identify target patients,

place presigned order sheets in medical records, obtain consent, and

vaccinate eligible patients before discharge.7

 Similar results were recently

obtained in community hospitals in Minnesota, in a study which also

indicated that standing orders for immunization were more effective than

physician reminders or physician education.8

Practice-Based

Tracking Systems

The promise of another strategy has been demonstrated in private practice

settings. This strategy builds on a target population-based model that has

been used successfully in childhood immunization programs and in the

Medicare Influenza Demonstration. Rather than rely on the number of

doses of vaccine distributed in a previous vaccination season to define

current goals, providers maintain posters showing the total number of

elderly patients in their practice who should be vaccinated and graph the

proportion who get immunized as the season progresses. A 1989 study

conducted in Monroe County, New York, showed that this strategy

increased the utilization of influenza vaccine among private practice

physicians assigned to an intervention group by 30 percent over those

assigned to a control group.9

Other Strategies

Vaccination Clinics Large numbers of vaccinations can be administered through public

vaccination clinics. However, there is less definitive information on the

factors that optimize this strategy’s success. In 1988, CDC, HCFA, and the

Hawaii Department of Health established the Hawaii Pneumococcal

Disease Initiative, which employed advertised mobile vaccination clinics

to increase vaccine use among older state residents. Before the initiative,

from 1982 to 1986, Medicare paid for an average of 1,103 doses of

pneumococcal vaccine per year. When the initiative began statewide in

7

Robert S. Klein and Nora Adachi, “An Effective Hospital-Based Pneumococcal Immunization

Program,” Archives of Internal Medicine, 146 (Feb. 1986), 327-29.

8

R.J. Crouse et al., “Hospital-Based Strategies for Improving Influenza Vaccination Rates,” Journal of

Family Practice, 38 (Mar. 1994), 258-61.

9

Joanna Buffington et al., “A Target-Based Model for Increasing Influenza Immunizations in Private

Practice,” Journal of General Internal Medicine, 6 (May-June 1991), 204-09. When surveyed, a majority

of physicians in the intervention group felt that using the posters created intra-office competition that

had a “moderate to high influence on immunization performance.” Physicians also attributed their

enhanced utilization of influenza vaccine to increased awareness of the actual number of elderly

patients in their practice.

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1987, Medicare paid for almost three times as many doses as in the

previous years. Moreover, in each of the following 2 years, when CDC and

HCFA joined the initiative, Medicare paid for almost 13 times as many doses

as in the years before the initiative. The fact that the number of

Medicare-reimbursed doses returned to the earlier levels when the

statewide initiative was over suggests that the vaccination clinics were

responsible for the observed increase in doses. However, like the

increases in immunization that accompanied the use of vaccination clinics

in California and Arizona, these changes may be partly attributable to

advertising or other events that coincided with the campaign.10

Public Information

Campaigns

Public health initiatives often use the mass media to disseminate

information. This strategy is frequently employed because it has the

potential to alert a broad audience relatively inexpensively by leveraging

the resources of the mass media. Assessing the effectiveness of public

information campaigns for the purposes of increasing immunization rates

is difficult.11 Nevertheless, such initiatives have been an integral part of

successful efforts to increase pneumococcal and influenza immunization

rates.12

Summary This chapter focused on four promising pneumococcal and influenza

immunization strategies: direct reminders to potential vaccinees, physician

reminder systems, standing orders for immunization in hospitals, and

practice-based tracking systems. The evidence in support of the

independent impact of public information campaigns and vaccination

clinics is somewhat less well developed.

Well-designed reminders, sent directly to consumers, have markedly

enhanced vaccine use. Mailing a letter or postcard to a potential consumer

is an opportunity to address specific vaccination-related concerns and,

possibly, to correct misperceptions. Evidence suggests that the most

effective reminders address a set of specific concerns (e.g., disease

10See “Successful Strategies in Adult Immunization,” Morbidity and Mortality Weekly Report, 40:41

(Oct. 18, 1991), 700-03, 709; and “Pneumococcal Immunization Program - California, 1986-1988,”

Morbidity and Mortality Weekly Report, 38:30 (Aug. 4, 1989), 517-19.

11There is evidence that public information campaigns in combination with other strategies (such as

vaccination clinics and Medicare reimbursement) are effective in increasing the levels of

pneumococcal and influenza immunization. However, we found no study that assessed the net effect

of a public information campaign on adult immunization rates.

12See AIDS Education: Reaching Populations at Higher Risk, (GAO/PEMD-88-35, Sept. 1988), especially

Chap. 2: A Model for Health Education.

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susceptibility, vaccine safety, and efficacy); however, they may also

influence consumer decision-making through the same mechanism

responsible for the observed impact of physicians’ recommendations for

vaccination.

Physician reminder systems—whether checklists in medical charts or

computer-based reminders—are used to remedy physicians’ tendency to

omit preventive health care practices. Similarly, the use of standing orders

in hospitals reduces the dependence on physicians’ remembering to

provide vaccinations. Higher vaccination rates also have been achieved by

transferring vaccination responsibilities to nonphysician health care

providers. Finally, population-based tracking systems have been used in

private practice settings to increase adult immunization rates by

identifying patients in need of vaccination.

Although evaluating their direct impact on vaccination rates is difficult,

public information campaigns and vaccination clinics have been part of

successful immunization strategies.

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Conclusions and Recommendations

Conclusions

Monitoring Adult

Immunization Rates

To monitor trends in both influenza and pneumococcal immunization rates

in noninstitutionalized elderly populations, HHS has relied primarily on the

National Health Interview Survey. These self-reported data represent the

best available information on national immunization rates. The

Department’s existing alternate methods for monitoring vaccine use

(manufacturers’ vaccine distribution reports maintained by CDC and

Medicare claims data maintained by HCFA) currently have substantial

limitations for calculating immunization rates.

Although HHS has conducted some research on immunization in nursing

homes, it has not routinely monitored immunization rates in these settings.

In response to our report, HHS noted that the National Center for Health

Statistics would begin collecting immunization data from nursing homes

as part of its survey efforts in fiscal year 1995 and will continue every

other year thereafter. As an indicator of quality of care, such information

could be valuable not only in monitoring immunization rates in this

high-risk population, but also in assisting state surveyors who review

nursing homes that participate in Medicare and Medicaid. Although HHS

officials note that HCFA’s guidance to states indicates that infection control

practices should be evaluated as part of reviews of nursing homes that

participate in Medicare and Medicaid, this designation refers generally to

the use of proper hygienic practices rather than emphasizing specific

disease prevention efforts. Reviewers might be assisted in evaluating

particular nursing homes’ provision of appropriate preventive services by

more systematic information on immunization practices in these facilities.

Death resulting from pneumococcal and influenza disease is much more

likely in persons with risk factors such as heart or lung disease. Thus,

monitoring of vaccination rates among these persons must allow for more

detailed analysis of potential causes for their underimmunization. Agency

officials told us that NCHS’ fiscal year 1995 survey methodology was

changed to permit such analyses by collecting data on both heart and lung

conditions from a larger portion of respondents.

Correlates of

Immunization Status

Multivariate analyses of 1991 data indicate that pneumococcal and

influenza vaccination rates were low across all subgroups in the elderly

population. However, controlling for other factors included in CDC’s

Page 48 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 6 

Conclusions and Recommendations

analyses, elderly persons who were black or who had not visited a

physician in the past year were markedly less likely to have received either

vaccination, while those with pulmonary disease or poor health status

were slightly more likely to have been vaccinated. Notably, although a

heart condition is a risk factor for complications from influenza, it was not

associated with increased likelihood of influenza immunization.

HHS Immunization

Strategies

In the 13 years since authorization of Medicare part B coverage for

pneumococcal vaccine, neither PHS nor HCFA has done much to enhance its

use among the elderly. Through its reimbursement of health care providers

for immunization services, HCFA makes the bulk of HHS expenditures

related to pneumococcal and influenza immunization. PHS dedicates few

resources to improving pneumococcal or influenza immunization rates.

Responsible officials of PHS’ NVPO, which is charged with establishing

federal vaccine priorities, indicated that they did not anticipate increasing

pneumococcal and influenza vaccination activities or resources. CDC

officials explained that their congressional appropriations committees

have focused on child immunization activities and that increased

expenditures on pneumococcal and influenza immunization would be

inconsistent with that focus. However, we believe that HHS has not

assumed a leadership role in seeking funding for an adult immunization

promotional effort commensurate with the significance of this public

health problem.

Explanations for Low

Immunization Rates

The tenable patient-based explanations for low levels of pneumococcal

vaccination are different from those for influenza vaccination. The elderly

are far less aware of pneumococcal vaccine than they are of influenza

vaccine. Though generally aware of influenza vaccine, the elderly tend to

underestimate the seriousness of influenza and their susceptibility to it. In

contrast, those elderly who are aware of pneumococcal vaccine tend to

have more accurate perceptions about the seriousness of pneumonia and

their susceptibility to this disease. Also, among those who are aware of the

vaccines, concerns about side effects, safety, and efficacy are more

prevalent for influenza than for pneumococcal vaccine.

Among potential health care provider-based explanations for low

immunization rates, those that focus on gaps in providers’ knowledge are

not as compelling as those addressing provider behavior. Data show that

most physicians are familiar with recommendations and indications

but—perhaps owing to limited record-keeping or various demands of

Page 49 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 6 

Conclusions and Recommendations

medical practice—physicians do not consistently offer immunization to

elderly patients.

Strategies to Improve

Vaccine Use

Among the steps that could improve rates of immunization, we believe that

measures related to vaccine provision are probably more important than

measures related to consumer demand. We base this conclusion on three

principal findings: (1) regardless of consumers’ attitudes about

pneumococcal and influenza vaccines, physicians’ recommendations are a

strong motivator for patients to get vaccinated; (2) the hospital setting

appears to provide important but largely missed opportunities for

vaccinating persons at high risk of complications from influenza or

pneumonia; and (3) the strategies we identified as promising means of

improving immunization rates generally either incorporated a

recommendation for vaccination or increased the likelihood that a

physician would make such a recommendation. We found relatively strong

evidence for the impact of physician and patient reminder systems, use of

standing orders in hospitals, and practice-based tracking systems.

Recommendations We recommend that the Secretary of HHS take a more active leadership

role in promoting pneumococcal and influenza vaccination among elderly

persons by (1) seeking, in the annual appropriations process, to clarify

what proportion of immunization funding should be allocated for such

activities; and (2) directing HCFA and PHS to focus their efforts on

promoting or supporting promising strategies, such as patient and

physician reminder systems, development of standing order policies, and

broad-based use of a hospital policy to vaccinate eligible patients before

discharge.

Agency Comments

and Our Response

Responsible officials from the Department of Health and Human Services

provided written comments on a draft of this report. (See appendix V.)

The Department provided additional, technical comments, which we

addressed in the body of the report as appropriate.

The Department generally agreed with us that more effort is needed to

increase rates of immunization among the elderly, particularly against

pneumococcal disease and in high-risk elderly and black populations.

Following review of our report, Department officials indicated that in

fiscal year 1997, CDC plans to propose an initiative in this area.

Page 50 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 6 

Conclusions and Recommendations

In addition to specific comments on our recommendations, the

Department made several general comments on the report. First, HHS

officials noted that we should use the Healthy People 2000 goals to

measure progress on these immunization rates. These are the criteria

against which we display the most current immunization data in both

chapter 1 and the executive summary. However, Department officials have

publicly described these goals as “modest.” Moreover, as the National

Vaccine Advisory Committee has indicated, current goals for these

immunizations were originally established in 1980 to target levels of

achievement for 1990, but were then carried forward to the year 2000

when they were not reached by 1990. It is also important to note that these

goals are identified as reasonable targets, not as optimal levels of

immunization.1

 If the preliminary data from HCFA’s beneficiary survey are

borne out in the forthcoming NHIS, it does appear that the year 2000 goal of

60-percent immunization for influenza could be attained, but it does not

appear that the year 2000 goal for immunization with pneumococcal

vaccine will be met. We observe that the Department agreed with us that

meeting the goal for pneumococcal immunization will require greater

efforts at promoting and supporting successful vaccination strategies.

The Department also commented that we had not provided a detailed

analysis of the recommendations made by PHS’ National Vaccine Advisory

Committee. We acknowledge that such an analysis was not included in the

scope of our evaluation. However, we did thoroughly review the NVAC

Report on Adult Immunization issued in January 1994 and the

recommendations made by the NVAC Subcommittee on Adult Immunization

in 1990. We found that the National Vaccine Plan does not indicate what

level of priority will be given to any of the NVAC’s 18 recommendations and

72 suggested strategies or what funds would be used to implement any or

all of them.

The Department quoted from the NVAC subcommittee report that,

“Programs to increase awareness must not focus simply on content

knowledge. . . . They must go further and address behaviors that affect

vaccine delivery.” However the Department’s comment did not specify

what steps it will take to effect such behavioral change. We agree that the

highest priority should be attributed to strategies to change the

immunization behavior of vaccine providers. However, much of the

Department’s comment suggests that emphasis will continue to rest on the

1

The Healthy People 2000 Review 1993, which documented progress toward year 2000 disease

objectives, noted that the rate of epidemic-related pneumonia and influenza deaths among persons

over 65 and the rate of their restricted-activity days because of pneumonia-related illness actually

increased between 1987 and 1992—moving away from established goals.

Page 51 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Chapter 6 

Conclusions and Recommendations

use of mass-media rather than more targeted approaches capable of

addressing provider behavior toward high-risk populations.

The Department did not agree with our recommendation to the Secretary

to seek clarification from the Congress as to the proportion of

immunization funding that should be allocated to activities to improve

these immunization rates. The Department stated that the Congress had

clearly guided CDC to place priority on childhood immunization. However,

our recommendation was based on our finding that an important reason

why the Congress had not emphasized the need for a public health role in

promoting immunization against pneumococcal disease and influenza was

that HHS had not taken a leadership role in promoting adult immunization

to the Congress.

With respect to our second recommendation, the Department has

indicated that it plans to continue its current activities to increase provider

and beneficiary awareness of the benefits of immunization. Although the

Department is correct that increasing such awareness is among the goals

cited by the NVAC’s Subcommittee on Adult Immunization, the

subcommittee has also identified the importance of support for specific

strategies, such as those included in our second recommendation. We

found that these strategies—patient and provider reminder systems, use of

standing orders for vaccination, and hospital policies to vaccinate

high-risk patients before discharge—are likely to be more effective than

the awareness promotion activities that HHS has indicated it will continue

to pursue.

Although the Department apparently agrees, it does not specify what will

be done to support or encourage the recommended strategies. Moreover,

given HHS’ conclusion regarding congressional priorities for immunization

funding, it is unclear how the Department could substantially increase its

promotion of pneumococcal and influenza immunization among older

adults without addressing our first recommendation—that it seek

congressional clarification about what proportion of immunization funding

should be allocated for this purpose.

Page 52 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Page 53 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix I 

HHS Data Collection on Factors That

Influence Vaccine Consumers’ Behavior

Data Collection

Efforts

Between the late 1970s and 1994, HHS undertook five studies to collect data

on consumer-based influences on receipt of immunization. Table I.1

identifies data collection agencies, describes major characteristics of

study designs, shows when studies were conducted, and indicates whether

information was collected on pneumococcal vaccination, influenza

vaccination, or both.

Table I.1: HHS Data Collection on Factors That Influence Vaccine Consumers’ Behavior

Organization Study design Year Pneumococcus Influenza

Opinion Research Corporation Two nationally representative surveys of

adults of all ages

1977-78 No Yes

Centers for Disease Control Survey using a nonrandom sample of 700

elderly in two counties in Georgia

1988 Yes Yes

CDC and Hawaii Department of Health Survey using a nonrandom sample of

14,000 elderly Hawaiians

1988 Yes Yes

Abt Associates Three surveys using random samples of

residents from 10 communities that

participated in the Medicare Influenza

Demonstration Project

1990-92 No Yes

National Institute on Aging Four focus groups with elderly men and

women

1992 Yes No

Source: ORC, CDC, Abt Associates, and NIA.

In 1977 and 1978, adults of all ages were surveyed by the Opinion Research

Corporation about six vaccine-preventable diseases, including influenza

but not pneumococcal infections. The survey (1) examined the

relationship between past experiences with vaccinations and current

desires to receive, or to have one’s children receive, them; and

(2) established baseline data on a variety of perceptions about vaccines.

HHS did not collect information on consumer-based barriers to

pneumococcal vaccination until 1987 and 1988, when CDC conducted two

studies of elderly respondents, one in two counties in Georgia and the

other in Hawaii. Both studies assessed vaccine awareness and various

related attitudes; however, the findings from these studies are not

generalizable beyond the study participants owing to the use of

nonrepresentative samples and the studies’ coverage of limited geographic

areas.

Each year from 1990 through 1992, HHS sponsored an Abt Associates

survey of Medicare beneficiaries living in 10 communities that participated

Page 54 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix I 

HHS Data Collection on Factors That

Influence Vaccine Consumers’ Behavior

in the Medicare Influenza Demonstration. Respondents who had not

received a flu shot during the last fall or winter were asked whether any of

11 potential reasons for not getting the flu shot had applied to them. (See

table I.2.) This is the only time HHS has directly assessed Medicare

beneficiaries’ reasons for not getting vaccinated.

Table I.2: Medicare Beneficiaries’

Reasons for Not Receiving Influenza

Vaccine

Reason Number Percent

Was healthy and didn’t need it 2,463 55

Heard you can still get the flu after getting the shot 1,703 38

Heard the shot can cause flu 1,670 37

Worried about the side effects 1,667 37

Never thought about it 1,292 29

Had a flu shot in the past and got the flu anyway 774 17

Doesn’t like the shots or needles 657 15

Doctor did not mention it 612 14

Doctor recommended against it 416 9

Didn’t want to spend the money 333 7

Has vaccine allergy 133 3

Source: Medicare Community-Dwelling Beneficiary Survey, Abt Associates, 1992.

In 1992, the National Institute on Aging commissioned four focus groups

on pneumococcal vaccination. Most participants were 65 years old or

older, and they were asked to discuss their attitudes toward preventive

health care and vaccinations, their familiarity with the pneumococcal

vaccine, and their reactions to information about it.

Limitations of the

Data

We found that all of the studies we reviewed are limited in at least one

respect that is important to our review. Only the ORC survey is nationally

representative, but it omits pneumococcal vaccine and was conducted

before Medicare coverage of pneumococcal and influenza vaccination.

CDC’s studies are more current, but they are not nationally representative,

and they do not examine why individuals failed to get vaccinated. The Abt

surveys inquire about reasons for not receiving influenza vaccination, but

they do not include pneumococcal vaccine, nor are they nationally

representative.

Page 55 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix II 

HHS Data Collection on Factors That

Influence Vaccine Providers’ Behavior

Data Collection

Efforts

Between 1980 and 1994, HHS undertook numerous studies to collect data

on a variety of factors that may influence providers’ immunization

behavior. Table II.1 describes these studies and indicates whether data

were collected on pneumococcal vaccination, influenza vaccination, or

both.

Table II.1: HHS Data Collection on Provider-Based Influences on Vaccination

Organization Study design Year Pneumococcus Influenza

Market Facts Survey of a nationally representative

sample of 1,000 primary care physicians

1980 Yes Yes

CDC, state health departments, HCFA, and

Abt Associates

Surveys of between 31 and 688 nursing

homes

1982-83,

1984-85,

1990-92

No Yes

CDC and Hawaii Department of Health Survey of all physicians practicing in Hawaii

(n=2,152)

1988 Yes Yes

CDC and American Managed Care and

Review Association

Survey of a representative sample (220 of

650) of HMOs with 25,000 members or more

1987-88 Yes Yes

CDC and Association of Teachers of

Preventive Medicine

Survey of medical students, medical

schools, and primary care residency

programs

1991 Yes Yes

National Institute on Aging Focus groups with primary care physicians 1992 Yes No

Centers for Disease Control and Prevention Survey of immunization program grantees 1993 No Yes

Source: CDC/NIP and NIA, 1994.

In 1980, CDC commissioned Market Facts to conduct a national survey of

primary care physicians to assess their knowledge of vaccine

recommendations, attitudes about vaccine safety and efficacy, sources of

vaccine information, and vaccination practices. Sixty-six percent of the

sample responded. Since 1982, CDC has directed several studies of

immunization policies and practices in nursing homes; none has been

nationally representative. The data collected include immunization rates

and descriptive information on the organization of influenza programs in

nursing homes and factors associated with varying rates of vaccine use

across homes.

As part of the Hawaii Pneumococcal Disease Initiative, CDC collaborated

with HCFA and the Hawaii Department of Health in 1988 to conduct a

survey of all physicians in active practice in Hawaii. Approximately

35 percent responded to the questionnaire, which assessed their intentions

to recommend pneumococcal and influenza vaccines, their attitudes about

Page 56 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix II 

HHS Data Collection on Factors That

Influence Vaccine Providers’ Behavior

vaccine safety and efficacy, and their use of immunization records in

patients’ charts and vaccination reminder systems.

In the winter of 1987-88, CDC commissioned a study of HMO adult

immunization policies. About 24 percent of those surveyed provided

information on pneumococcal and influenza vaccine coverage, adult

vaccination policy, promotion of adult vaccination, and immunization

practices. In 1991, CDC commissioned a survey of U.S. medical schools and

primary care residency programs to assess the existence, duration, and

content of education about adult immunization and vaccine-preventable

diseases of adulthood.1

In November 1992, NIA commissioned four focus groups with primary care

physicians in public clinics and private practice in Richmond and

Philadelphia. The groups discussed their thoughts on routine vaccination

of adults, awareness and assessment of pneumococcal vaccine,

communication with patients about the vaccine, and barriers to

administering the pneumococcal vaccine.

CDC provided us with some preliminary information from its 1994 survey of

immunization program grantees on their experiences in providing

influenza immunization as a Medicare benefit through state and local

health departments. In addition, CDC recently compiled a survey of

hospitals’ flu and pneumococcal immunization policies and provided

major findings in comments on our draft report.

Limitations of the

Data

In addition to the limitations mentioned above in connection with

individual studies, we note that HHS lacks recent information from a

representative sample of physicians, including specialists such as

cardiologists and pulmonary doctors who regularly see patients at high

risk for pneumonia and influenza. (Although the Department conducted a

detailed and informative national survey of primary care physicians in

1980, it was completed before Medicare coverage was offered for either

vaccine.) HHS has also lacked information on vaccination policies and

practices from a national sample of nursing homes. Finally, the low

response rates to physician and HMO surveys also present a barrier to a

fuller understanding of the reasons for low immunization rates.

1

At the time of our review, CDC was planning another physician survey, but it was not designed to be

nationally representative.

Page 57 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix III 

Sample Notice of Medicare Coverage for

Influenza Vaccine Incorporated in Mailings

Associated With Medicare Claims

Page 58 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix IV 

Administrator’s Letter to Beneficiaries

During the Medicare Influenza

Demonstration

Page 59 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix V 

Comments From the Department of Health

and Human Services

Page 60 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix V 

Comments From the Department of Health

and Human Services

Page 61 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix V 

Comments From the Department of Health

and Human Services

Page 62 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix V 

Comments From the Department of Health

and Human Services

Page 63 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix V 

Comments From the Department of Health

and Human Services

Page 64 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix V 

Comments From the Department of Health

and Human Services

Page 65 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
Appendix VI 

Major Contributors to This Report

Program Evaluation

and Methodology

Division

Sushil K. Sharma, Assistant Director

Betty A. Ward-Zukerman, Assignment Manager

Jason S. Lee, Project Manager

Venkareddy Chennareddy, Referencer

Elizabeth W. Scullin, Communications Analyst

(973782) Page 66 GAO/PEMD-95-14 Pneumococcal and Influenza Immunization
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