General Best Practice Guidelines for Immunization: Vaccination Programs 177

11. Vaccination Programs

Updates

The major revision to this section is the addition of language related to Affordable Care 

Act (1) coverage of adult vaccination.

 

General Principles

Universal vaccination is a critical part of quality health care and should be accomplished 

through routine and catch-up vaccination provided in physicians’ offices, public health 

clinics, and other appropriate settings. In the United States, vaccination is considered 

primarily the responsibility of individual health care providers and health care systems 

serving patients.

Certain programs and other efforts attempt to ensure all patients receive the full schedule 

of appropriate vaccinations by removing barriers posed by access to immunizations, cost, 

or other factors. Such efforts may include school-located clinics, school-based health 

centers, back-to-school immunization clinics, public health clinics for schoolchildren, 

periodic influenza vaccination clinics, public health nurse tracking of childhood 

immunizations, and government-sponsored financing of vaccines through the Vaccines for 

Children and Section 317 program (www.cdc.gov/vaccines/hcp/admin/vfc.html).

In the United States, vaccination programs have eliminated many vaccine-preventable 

diseases and markedly reduced the incidence of others (2). Because infants and young 

children were the principal recipients of most vaccines developed during the twentieth 

century (e.g., poliovirus vaccine), many persons in the United States might believe that 

vaccinations are solely for the young; however, vaccinations are recommended for persons 

of all ages (3,4). Improved vaccination coverage can result in additional reductions in the 

incidence of vaccine-preventable diseases that affect persons throughout the life span, and 

decrease associated morbidity and mortality. 
General Best Practice Guidelines for Immunization: Vaccination Programs 178

Vaccination of Children and Adolescents

Physicians and other pediatric vaccination providers should adhere to the standards for 

child and adolescent vaccination practices (5). These standards are published by the 

National Vaccine Advisory Committee and define appropriate vaccination practices for 

both public and private sectors. The standards provide guidance on practices that 

eliminate barriers to vaccination, including eliminating unnecessary prerequisites for 

receiving vaccinations, eliminating missed opportunities to vaccinate, improving 

procedures to assess vaccination needs, enhancing knowledge about vaccinations among 

parents and providers, and improving management and reporting of adverse events. In 

addition, the standards address the importance of recall and reminder systems and using 

assessments to monitor clinic or office vaccination coverage levels. Health-care providers 

should simultaneously administer as many vaccine doses as possible as indicated on 

the Recommended Immunization Schedules for Persons Aged 0 Through 18 Years (3).

While rates of childhood vaccination are generally higher than rates of adult vaccination, 

for some doses coverage rates are still low, like the birth dose of hepatitis B vaccine. 

Community health-care providers, as well as state and local public health vaccination 

programs, should coordinate with partners to identify and maximize outreach to 

populations at risk for undervaccination and vaccine-preventable diseases. For example, 

the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a 

categorical federal grant program administered by the U.S. Department of Agriculture 

through state health departments. The program provides supplemental foods, health-care 

referrals, and nutrition education to low-income pregnant, breastfeeding, or postpartum 

women, as well as to infants and children aged

<5 years. Between 8.5 and 8.9 million people participated in this program in 2013 

(www.fns.usda.gov/pd/wic-program). In collaboration, WIC and state vaccination 

programs assess regularly the vaccination coverage levels of WIC participants and develop 

new strategies and aggressive outreach procedures in sites with coverage levels

<90%. 
General Best Practice Guidelines for Immunization: Vaccination Programs 179

Vaccination programs and private providers are encouraged to refer eligible

children to obtain WIC nutritional services, at www.fns.usda.gov/wic/immunizationscreening-and-referral-wic (6).

Adolescent-Specific Issues

Vaccinations are recommended throughout life, including during adolescence. The age 

range for adolescence is defined as 11-21 years by many professional associations, 

including the American Academy of Pediatrics and the American Medical Association 

(7,8). Definitions of these age cutoffs differ depending on the source of the definition and 

the source’s purpose for creating a definition. Vaccination of adolescents is critical for 

preventing diseases for which adolescents are at particularly high or increasing risk, such 

as meningococcal disease and human papillomavirus infection. Three vaccines 

recommended for adolescents have been licensed since 2005: MenACWY and Tdap were

licensed in 2005, and HPV was licensed in 2006. A second dose of varicella vaccine is 

recommended for persons who received 1 dose of varicella vaccine after age 12 months. In 

addition, annual seasonal influenza vaccination is recommended for persons aged >6 

months who have no contraindications. To ensure vaccine coverage, clinicians and other 

health-care providers who treat adolescents must review vaccination history on every 

occasion that an adolescent has an office visit.

National goals for vaccination coverage for adolescents aged 13-15 years were included in 

Healthy People 2020, at www.healthypeople.gov/2020/topicsobjectives/topic/immunization-and-infectious-diseases. Targets of 80% coverage were 

specified for one dose of Tdap, one dose of meningococcal conjugate vaccine, and 3 doses 

of HPV vaccine. Results of the published 2014 National Immunization Survey—Teen 

indicate that coverage rates for 13-17 years olds is 87.6% for one dose of Tdap and 79.3% 

for one dose of meningococcal vaccine. Coverage rates for 13-17 years olds for HPV vaccine 

are considerably lower—39.7% for females and 21.6% for males (9,10).

Ensuring adolescents receive routine and catch-up vaccination and achieving high levels 

of vaccination coverage present challenges. In general, adolescents do not visit health care 

providers frequently. Health care providers should promote annual preventive visits (11), 

including one specifically for adolescents aged 11 and 12 years. 
General Best Practice Guidelines for Immunization: Vaccination Programs 180

The annual visits should be used as opportunities to provide routinely recommended 

vaccine doses, additional catch-up doses needed for lapsed vaccine series, vaccines 

recommended for high-risk groups, additional doses that might have been recently 

recommended, and other recommended health-care services. Additional strategies include 

adolescent immunizations at community-based venues such as pharmacies and schools.

All vaccine doses should be administered according to ACIP vaccine-specific statements 

and with the most recent schedules for both routine and catch-up vaccination. Before 

leaving any visit for medical care, adolescents should be encouraged to schedule return 

visits for any additional vaccine doses needed. During visits that occur outside of influenza 

season, providers should discuss and recommend seasonal influenza vaccination and 

make explicit plans for vaccination, including timing and anticipated setting (e.g., health 

care provider’s office, school, or pharmacy). Catch-up vaccination with multidose 

adolescent vaccines generally can occur according to the routine dosing schedule for these 

vaccines, although in some circumstances the clinician or health care provider might use 

minimum intervals for vaccine doses. These circumstances include an outbreak that 

increases risk for disease or the likelihood that doses will be missed in the future (e.g., 

because of transportation challenges). Because of lack of efficacy data for HPV vaccine 

administration using minimum intervals, providers are encouraged, when possible, to use 

routine dosing intervals for females aged 11-26 years and males aged 11-21 years who have 

not yet received 3 HPV vaccine doses as recommended (3,4).

One of the challenges of adolescent vaccination is ensuring that current, complete 

vaccination histories are available. Insurers, covered services, or reimbursement levels can 

change, and these changes might affect reimbursement for vaccine doses and vaccination 

services directly while also causing disruptions in an adolescent’s access to vaccination 

providers or venues. In circumstances in which a vaccination record is unavailable, 

vaccination providers should attempt to obtain this information from various sources 

(e.g., parent, previous providers, or school records). More detail about how to obtain these 

records is available from CDC at www.cdc.gov/vaccines/hcp/admin/immunizrecords.html. With the exception of influenza and pneumococcal polysaccharide vaccines, 

if documentation of a vaccine dose is not available, the adolescent should be considered 

unvaccinated for that dose. 
General Best Practice Guidelines for Immunization: Vaccination Programs 181

Regardless of the venue in which an adolescent receives a dose of vaccine, that vaccine 

dose should be documented in the patient’s chart or in an office log, and the information 

should be entered into an IIS. The adolescent also should be provided with a record that 

documents the vaccination history.

Adult Vaccination

In 2013, the National Vaccine Advisory Committee published updated standards for adult 

vaccination (12). These standards are targeted to distinct groups involved in adult 

vaccination, including immunizing providers, non-immunizing providers, professional 

health-care organizations, and public health departments. All health-care providers, 

whether they provide immunizations or not, should incorporate immunization needs 

assessment into every clinical encounter, strongly recommend needed vaccine(s) and 

either administer vaccine(s) or refer patients to a provider who can immunize, stay up-todate on, and educate patients about vaccine recommendations, implement systems to 

incorporate vaccine assessment into routine clinical care, and understand how to access 

immunization information systems (i.e., immunization registries) (12).

Vaccination rates in adults are considered suboptimal (13,14). New Healthy People 

2020 goals include specific subsets of adults, including institutionalized adults aged ≥18 

years (for pneumococcal vaccines) and noninstitutionalized adults at high risk aged >18 

years (for pneumococcal vaccines) (9).

The most substantial barrier to vaccination coverage is lack of knowledge about these 

vaccines among adult patients and adult providers. Other barriers are cost (incomplete 

Medicare coverage for recommended vaccines) (15) and the lack of financing mechanisms 

for newly licensed and recommended vaccines. Effective for private health insurance plans 

drafted or updated after September 2010, coverage for all immunizations that are included 

on the immunization schedule(s) must be covered without deductibles or co-pays, when 

delivered by an in-network provider. For this reason, cost may present less of a barrier to 

adult vaccination as time passes.
General Best Practice Guidelines for Immunization: Vaccination Programs 182

A common challenge for health-care providers is vaccinating adults with unknown 

vaccination records. In general (except for influenza and pneumococcal polysaccharide 

vaccines), adults should receive a vaccine dose if the dose is recommended and no record 

of previous administration exists. If an adult has a record of military service and does not 

have records available, providers can assume that the person has received all vaccines 

recommended by the military at the time of service entry. Serologic testing might be 

helpful in clarifying immune status if questions remain, because at different times and 

depending on military assignments, there might be inter-service and individual 

differences.

Evidence-based Interventions to Increase Vaccination 

Coverage

The independent, nonfederal Task Force on Community Preventive Services, whose 

membership is appointed by CDC, provides public health decision-makers with 

recommendations on population-based interventions to promote health and prevent 

disease, injury, disability, and premature death. The recommendations are based on 

systematic reviews of the scientific literature about effectiveness and cost-effectiveness of 

these interventions. In addition, the task force identifies critical information about the 

other effects of these interventions, the applicability to specific populations and settings, 

and the potential barriers to implementation. Additional information, including updates 

of published reviews, is available from The Community Guide at 

http://www.thecommunityguide.org. 

Beginning in 1996, the task force systematically reviewed published evidence on the 

effectiveness and cost-effectiveness of population-based interventions to increase coverage 

of vaccines recommended for routine use among children, adolescents, and adults. A total 

of 197 articles were identified that evaluated a relevant intervention, met inclusion 

criteria, and were published during 1980-1997. Reviews of 17 specific interventions were 

published in 1999 (13,14,16,17). Using the results of their review, the task force made 

recommendations about the use of these interventions (15). Several interventions were 

identified and recommended on the basis of published evidence. Follow-up reviews were 

published in 2000, and a review of interventions to improve the coverage of adults at high 

risk was conducted in 2005 (15,17). 
General Best Practice Guidelines for Immunization: Vaccination Programs 183

The interventions and the recommendations are summarized in this section of this report 

(Table 11-1). Interventions designated for adults younger than 65 years at high risk for 

influenza, invasive pneumococcal disease, and hepatitis B, include provider reminder 

systems or a menu of items (combinations of strategies ) (Table 11-2). In 1997, the task 

force categorized vaccination requirements for child care, school, and college as a 

recommended strategy (14).

A 2008 update of the original task force systematic review of the evidence on the 

effectiveness of provider assessment and feedback for increasing coverage rates found that 

this strategy remains an effective intervention (18). This later update reviewed 19 new 

studies published during 1997-2007. The updated review supports the original task force 

recommendation for use of assessment and feedback based on strong evidence of 

effectiveness. The task force reviewed studies of assessment and feedback as a strategy 

that were conducted in a range of settings, including private practice, managed care, 

public health, community health settings, and academic centers. Studies have assessed the 

effectiveness of this intervention to improve coverage with MMR, DTP, DTaP, Hib, 

influenza, pneumococcal, and Td vaccines (16). The most updated information on this 

review is available at www.thecommunityguide.org/findings/vaccination-programsprovider-assessment-and-feedback. As recognized by the task force, routine assessment 

and feedback of vaccination rates obtained at the provider site is one of the most effective 

strategies for achieving high, sustainable vaccine coverage. Since 1995, all states receiving 

federal funds for vaccination programs have been required to conduct annual assessments 

of vaccination rates both in public health clinics and in private provider offices. Primarily 

to aid local and state health departments in their efforts to conduct assessments and assist 

providers, CDC has developed numerous software applications to measure vaccination 

rates in provider practices.

Other General Programmatic Issues

Programmatic challenges, evolving issues, and effective interventions related to adult and 

adolescent vaccination programs have been described by other advisory groups and expert 

groups. Additional evidence-based approaches are being developed for certain issues (e.g., 

settings for adolescent vaccination delivery) through ongoing research and evaluation. 
General Best Practice Guidelines for Immunization: Vaccination Programs 184

Among current programmatic challenges, vaccine financing is especially difficult because 

certain problems and solutions differ markedly from one state to another. Practitioners 

interested in beginning or continuing to provide vaccinations to patients are encouraged 

to consult with local and state public health vaccination programs to learn about publicly 

funded programs that might be available in their areas for patients who need vaccination 

but have insufficient health insurance coverage and no financial resources. If not already 

participating, providers who care for adolescents and children aged <19 years should 

enroll in the Vaccines for Children Program 

(www.cdc.gov/vaccines/hcp/admin/vfc.html). Through this program’s provision of ACIPrecommended, federally purchased vaccines, participating providers are able to fully 

vaccinate eligible children whose parents might not otherwise be able to afford the 

vaccinations. Interested providers are encouraged to work with insurers, state and 

specialty-specific medical organizations, vaccine manufacturers, and other stakeholders to 

address financial barriers to achieving high vaccination coverage. With availability of safe 

and effective vaccines for 18 vaccine-preventable diseases, the capacity for realizing the 

potential benefits of these products in the United States depends on reaching children, 

adolescents, and adults through dedicated, knowledgeable vaccination providers and 

efficient, strong vaccination programs at local, state, and federal levels.
General Best Practice Guidelines for Immunization: Vaccination Programs 185

TABLE 11-1. Recommendations regarding interventions to improve 

coverage of vaccines recommended for routine use among children, 

adolescents, and adults

Intervention Recommendation

Increase community demand for vaccination

Client reminder or recall systems Recommended

Requirements for entry to schools, child- care 

facilities, and colleges

Recommended

Community education alone Insufficient evidence

Community-based interventions implemented in 

combination

Recommended

Clinic-based education Insufficient evidence

Patient or family incentives Recommended

Patient or family monetary sanctions Insufficient evidence

Client-held medical records Insufficient evidence

Enhance access to vaccination services

Reducing out-of-pocket costs Recommended

Enhancing access through the U.S. Department of 

Agriculture’s Women, Infants, and Children (WIC) 

program

Recommended

Home visits, outreach, and case management 

targeted to particularly hard-to-reach populations 

to increase vaccination rates

Recommended

Enhancing access at schools Recommended

Expanding access in health-care settings Recommended as part of 

multicomponent interventions 

only

Enhancing access at organized child care centers Recommended

Focus on providers

Provider reminder or recall systems Recommended
General Best Practice Guidelines for Immunization: Vaccination Programs 186

Provider assessment and feedback Recommended

Standing orders Recommended

Provider education alone Insufficient evidence

Health-care systems-based interventions 

integrated in combination

Recommended

Immunization information systems Recommended

Source: www.thecommunityguide.org/topic/vaccination.
General Best Practice Guidelines for Immunization: Vaccination Programs 187

TABLE 11-2. Strategies to improve influenza, pneumococcal 

polysaccharide, and hepatitis B vaccine coverage among high-risk adults 

younger than 65 years

One or both of these interventions to 

improve access to vaccination services

1. Expanded access in health-care settings

2. Reducing client out-of-pocket costs

PLUS:

One or more of these provider or system 

based interventions

1. Standing orders

2. Provider reminder systems

3. Provider assessment or feedback

AND/OR:

One or both of these interventions to 

increase client demand for vaccination 

services

1. Client reminder systems

2. Client education

Source (15)
General Best Practice Guidelines for Immunization: Vaccination Programs 188

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