April 1996
ATLANTA—An assessment program was so successful in raising immunization coverage rates in Georgia that the Advisory Committee on Immunization Practices (ACIP) is urging other states to adopt similar strategies.
At its recent meeting, the ACIP recommended a regular assessment of clinic and provider immunization rates "including feedback on vaccine delivery practices to motivate providers and staff to improve immunization practices. Implementation of these recommendations will contribute markedly to improving vaccination rates among all providers of childhood vaccines," according to the resolution.
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Georgia's assessment program was simply an annual review of vaccination records to assess vaccination coverage levels and missed opportunities for immunization. Clinics received feedback on their rates, and plaques were awarded to health districts and clinics that met coverage goals. In addition, maps of coverage and a rank-order list were distributed.
The strategy more than doubled coverage levels in public clinics. At the start of the project in 1985, fewer than 40% of 2-year-old children served by public sector clinics had been fully immunized (i.e., four doses of diphtheria-tetanus-pertussis vaccine, three doses of oral polio vaccine, and one dose of measles-mumps-rubella vaccine). By 1989, coverage rates for these children had risen to 80%. The goal is for 90% coverage by 2000.
The assessment and feedback system had the most immediate impact on reducing the number of missed opportunities for simultaneous vaccination, said Charles LeBaron, MD, of the National Immunization Program, Centers for Disease Control and Prevention (CDC).
"Missed opportunity rates started in the high teens," LeBaron said. "They basically crashed over a period of 4 years down to a median of zero."
The program was less effective in reducing the number of children who began the immunization series late (late starts) and in reducing the number of children lost to follow up.
"That would be consistent with the hypothesis that there is something operating on the providers to change their behavior," LeBaron said. "We presume missed opportunities are mostly under providers' control; lost contacts are somewhat under providers' control but also are under control of the parents. Providers are least able to affect [late starts]."
The gains made by Georgia's assessment program came at a low cost. "This [project] took a birth cohort equivalent to [the population of] New York City and increased coverage from 25% to 85% in about 9 years with six people using 25% of their time," LeBaron said.
Assessment and feedback programs are gaining popularity. Coverage rates in Colorado, Illinois, Indiana, Iowa, and South Carolina increased after similar programs were introduced in public clinics, and Arizona, Massachusetts, New York, and Washington have reported limited experience with an assessment program in managed care settings.
The CDC has thrown its weight behind assessment programs. Some type of annual immunization assessment is now required for states to receive grant funds, said Walter A. Orenstein, MD, Director of the CDC's National Immunization Program.
"The issue now is how do we get private-sector physicians and managed care organizations to take on similar efforts," Orenstein said.
For more information, see:
- CDC. Evaluation of vaccination strategies in public clinics—Georgia, 1985-1993. MMWR 1995;44:323-25.
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