Driving Public Health Goals: A Look at Successful Innovative Vaccination Initiatives

Routine vaccination as a public health initiative is one of the most cost-effective and successful health care interventions in the population-health arsenal.¹ The benefits of high vaccine uptake are multifaceted and have far-reaching implications because vaccines play a pivotal role in preventing and controlling the spread of infectious diseases within communities.² Despite the enormity of evidence that demonstrates the value of life-course immunization (ie, the concept of vaccination providing protection throughout and individual’s life), barriers to vaccination persist and vaccination rates remain low for many routinely recommended vaccines.³ National Health Interview Survey data from 2018 indicate that few adults in the United States have received all age-appropriate vaccines, including those against influenza; pneumococcus; herpes zoster; tetanus; tetanus and diphtheria; tetanus, diphtheria, and pertussis (Tdap); and component vaccines against hepatitis A, hepatitis B, and human papillomavirus (HPV).³ The survey results revealed that vaccination rates remained low even among individuals who had health insurance and at least 10 physician contacts throughout the year, highlighting the need to incorporate vaccine initiatives into current practice to reduce missed vaccination opportunities.³

Vaccination Programs and Initiatives

Vaccine-preventable diseases (VPDs) are associated with considerable economic and clinical impact on both individuals and health care systems, as well as increased health care utilization. The treatment of VPDs in adults was associated with an estimated annual expenditure of nearly $27 billion in the United States in 2013, or $35.2 million in 2023 USD.^4,5 (Note: the adjusted number is based only on the dollar amount and do not take into account other factors such as new therapies.) To ensure a healthier future and a sustainable health system, substantial improvements in vaccine uptake are needed to reduce the burden of VPDs.

Innovative programs and vaccination initiatives are necessary to meet the challenge of increased vaccine uptake. Successful programs have demonstrated meaningful increases in vaccination rates among specific populations. For example, during 2019-2021, a pharmacist-led pneumococcal vaccine initiative which targeted patients with cancer in an outpatient oncology clinic setting showed an increase in pneumococcal vaccination rates to 20.2% compared with 6.1% in the control group—an increase of 231%.⁶ Results of another program, this time for herpes zoster vaccination in community pharmacies, showed a 224% increase in vaccination rates.⁷ Successful vaccination programs tailor messages to their target population, expand access and delivery of vaccines, and utilize a data-driven approach to meet effectiveness goals. All stakeholders, including payers and employer groups, have a vested interest in supporting creative and innovative approaches to vaccination initiatives as a measure of public health.

The success of these programs aids in achieving public health goals set forth by the US Department of Health and Human Services and the National Vaccine Advisory Committee (NVAC).⁸ Healthy People 2030 aims to prevent infectious diseases by increasing vaccination rates (Figure 1).⁹ In addition to maintaining public health, ensuring target populations achieve optimal vaccination rates is a requirement for the Healthcare Effectiveness Data and Information Set (HEDIS) developed by the National Committee for Quality Assurance.¹⁰ Although HEDIS measures are used widely by a variety of commercial, federal, and state entities (including Medicaid and the Children’s Health Insurance Program) to evaluate the performance of health care products, programs, and services (Table^11-14), vaccine uptake remains well below national targets across many populations.^15-18 Understanding the reasons behind these low rates is imperative to increasing vaccination rates.

Understanding Vaccination Challenges

Barriers and challenges to vaccine uptake persist among different age groups and patient populations, contributing to the current suboptimal rates of vaccination. Barriers can vary depending on the type of vaccine and the target population, but they often include lack of access, high out-of-pocket costs, vaccine hesitancy, vaccine misconceptions, lack of education, and fear of immunization pain.^19-21

RSV

Adults 65 years and older continue to face heightened vulnerability to VPDs, such as respiratory syncytial virus (RSV), due to a combination of waning immunity and a higher prevalence of comorbidities within this demographic.²² These factors increase the susceptibility of older adults to infections as well as elevate the likelihood of experiencing severe illness.²² Programs aimed at boosting vaccine coverage rates among adults older than 50 years are limited, leading to suboptimal uptake of vaccines in this age group (Figure 2).^22-25 Infants and young children also face an increased susceptibility to VPDs due to an undeveloped and immature immune system; the risk is especially high among those born premature or with weakened immune systems.^26-28

In May 2023, the FDA approved the first RSV vaccines for adults 60 years and older (Abrysvo; Pfizer) (Arexvy; GSK).^29,30 Prior to the vaccines’ approvals, the results of a March 2023 survey revealed that most older adults were not aware of RSV vaccines, with only 35% of those 60 years and older having heard of an RSV vaccine.³¹ In August 2023, Abrysvo received FDA approval for use in pregnant individuals at 32 to 36 weeks’ gestation to prevent lower respiratory tract disease from RSV infection in infants from birth to 6 months of age.³² Awareness and educational campaigns will be needed to socialize the launch of these novel RSV vaccines to increase uptake in their target populations.

HPV

More than a decade has passed since the Advisory Committee on Immunization Practices (ACIP) of the CDC recommended routine use of the HPV vaccine in male adolescents in 2011, expanding on its original recommendation for vaccination in female adolescents in 2007.^33,34 Currently, the CDC recommends routine HPV vaccination starting at age 9 years and catch-up vaccination for all individuals through age 26 years. Shared clinical decision-making is recommended for some adults through age 45 years who are not adequately vaccinated.³⁵ However, despite the public health commitment supporting ACIP’s recommendation, coverage for HPV vaccination in the United States remains comparatively lower than that of other vaccines recommended for the same age group.²⁴ According to data from the 2017 National Immunization Survey-Teen, 88.7% of teens had received at least 1 dose of the Tdap vaccine, and 85.1% had received at least 1 dose of MenACWY (meningococcal ACWY) vaccine between the ages of 13 to 17 years.³⁶ However, results of the same survey revealed that only 65.5% of adolescents had received at least 1 dose of the HPV vaccine, and just 48.6% completed the HPV vaccine series.³⁶ These findings highlight a notable disparity, indicating that whereas Tdap and MenACWY coverage rates are high, many teens remain unprotected against HPV infections and HPV-related cancers. According to 2013-2018 data from the National Center for Health Statistics, HPV coverage rates are further eroded among young adults, with only 21.5% of 18-26-year-olds completing the vaccine series.³⁷

Five main contributing factors for low HPV vaccination coverage as outlined by NVAC are: (1) differing perspectives on risks of getting an HPV-associated cancer vs the protective benefits offered by receipt of the vaccine, (2) a substantial percentage of adolescents do not regularly visit a primary care provider for preventive care, (3) parental refusal, (4) lack of a strong recommendation from a provider relative to other adolescent vaccines, and (5) lack of HPV vaccine mandates, such as a requirement for school entry (Figure 2).^22-25 Research also has identified parental concerns about the vaccine’s cost and impact on their child’s sexual behavior as potential barriers to vaccine uptake.³⁸ Among routinely recommended pediatric vaccines, the HPV vaccine holds the distinction of being the most expensive, at a list price of $286.78 per dose, given in a 2-3-dose series per indication.^39,40 Barriers to adult immunization differ from adolescents and may include a lack of perceived need for the vaccine in a married or monogamous relationship or the perception that their health insurance may not pay for the HPV vaccine.⁴¹ Providing vaccine education to patients and caregivers, ensuring access to immunization, and safeguarding sufficient reimbursement by third-party payers play a pivotal role in facilitating health care providers’ sustained ability to provide these vaccines.^24,38,39

Influenza

Stark inequalities continue to exist in influenza vaccine uptake among racial and ethnic groups.^3,25 During the 2021-2022 influenza season, influenza vaccination coverage was 54% among White adults, whereas coverage for Black adults, Hispanic adults, and American Indian/Alaska Native adults trailed at 42%, 38%, and 41% respectively.²⁵ Racial and ethnic disparities in influenza vaccination rates stem from a multitude of factors, including limited access to health care and insurance, missed opportunities for vaccination, and misinformation that leads to distrust (Figure 2^22-25).^22,25 Structural racism and prejudice can exacerbate these disparities, further eroding confidence in influenza vaccination.⁴² Mistrust in the medical system in the historical context of systemic racism, misconceptions about vaccine safety, and heightened concerns about adverse reactions have contributed to lower vaccine coverage among individuals of racial and ethnic minority groups.^22,25 Additionally, these individuals may encounter obstacles to accessing affordable, quality health care, including lack of health insurance, difficulties in reaching health care providers due to transportation limitations, and challenges with child care, all of which perpetuate these inequalities.²⁵ Programs engineered to build trust and increase access through community-level interventions are needed to reduce disparities in influenza vaccination.

Low vaccine uptake carries considerable implications for both public health and managed care decision makers, reverberating through various dimensions of health care and society as a whole. Implications to public health include increased disease burden, higher rates of morbidity and mortality, and exacerbated inequalities in access to health care.^1,2,25 Managed care decision makers should consider the downstream effects of low vaccine uptake, such as increased health care utilization and potentially avoidable health care costs.^4,6 The consequences of inadequate vaccine coverage underscore the vital role of innovative strategies to promote and ensure widespread vaccine uptake.

Overview of Innovative Programs

The Community Preventive Services Task Force suggests employing a blend of community-centered strategies to increase vaccination rates within specific populations.⁴³ These strategies might encompass initiatives to bolster community demand, facilitate vaccination service accessibility, or reduce missed vaccination opportunities by health care providers.³⁸

HPV Vaccination NOW: This is Our Moment, an innovative social media campaign by the South Carolina Cancer Alliance and Hollings Cancer Center at the Medical University of South Carolina, achieved success in building confidence in and increasing parental awareness of HPV vaccination in South Carolina through the use of ads with messages vouching for the safety and efficacy of the HPV vaccine.⁴⁴ Social media platforms such as Facebook and Twitter were engaged to target parental awareness during the 2019 period of back-to-school medical appointments, reaching more than 33,000 individuals and gaining 1122 followers.⁴⁴

Another example is a study conducted between 2020 and 2021 that tested a new approach involving a household-based outreach program via the use of Epic’s MyChart patient portal messages and/or interactive voice response telephone calls. During this period, vaccination for influenza increased by 3.3%.⁴⁵ These program examples spotlight the success of novel and inventive approaches to vaccination campaigns.

Key Components of Successful Innovative Programs

These common threads can be identified throughout successful innovative vaccination programs: tailored messaging and communication strategies; creative access and delivery mechanisms; and data-driven approaches and continuous evaluation (Figure 3).^25,45,46

Effective messaging techniques are essential to reach the targeted population for vaccination. A qualitative review demonstrated that more successful pharmacy-based interventions involved active, in-pharmacy communication such as proactive conversations, screenings, and recommendations about vaccinations rather than passive communication through leaflets and posters.⁴⁶ Newer technology and digital platforms can be harnessed for communication strategies targeting a specific audience, such as the social media campaign described earlier, by creating a digital footprint and engaging with individuals.⁴⁴ Collaboration with community influencers and trusted sources is needed to combat misinformation and promote accurate, culturally responsive vaccine messages.²⁵

Expanding access to vaccines through creative delivery mechanisms is necessary to increase vaccine uptake in historically underserved communities. Pop-up site programming efforts, such as Partnering for Vaccine Equity: Equity in Adult Vaccination, bring vaccines to communities through nontraditional vaccine settings. This initiative, launched by the CDC in 2020, has helped decrease disparities in COVID-19 vaccination rates by offering vaccines in libraries, barbershops, thrift stores, restaurants, and grocery stores.²⁵ In addition, building upon an existing framework for health care services and settings can close the missed vaccination opportunity gap. Provider services can help close this gap and improve vaccination rates; research has shown that recommendations from a provider remain a strong predictor of vaccination.^19,47-49

Data analytics and measured outcomes analysis can be utilized in program design and evaluation of interventions. As a resource allocation tool, data can inform where efforts are most critically needed. For example, vaccine administration data from the Utah Statewide Immunization Information System was used to conduct one of the first studies to utilize state immunization information system data to identify missed opportunities for HPV vaccination.⁴⁶ Deidentified vaccination records of more than 25,000 females (aged 11-26 years) who received at least 1 dose of the Tdap, meningococcal, and/or influenza vaccines between 2008 and 2012 were included in the analysis to identify missed opportunities for HPV vaccination. Missed opportunities were defined as any clinical encounter with a provider where the patient did not receive an HPV vaccine but received at least 1 of the other adolescent vaccinations previously mentioned.⁵⁰ According to the analysis, approximately 44% of clinical encounters were found to be missed opportunities, highlighting the importance of data utilization to measure intervention outcomes.⁵⁰ The identification of such missed opportunities gives providers a better understanding of the efficacy of vaccine delivery systems in place and can help guide decisions and strategies to optimize future initiatives and allocate resources.

Regular monitoring and evaluation of program effectiveness can highlight successes, such as an analysis demonstrating increased adolescent HPV and meningococcal uptake rates through Arizona’s statewide immunization registry following the implementation of school-entry vaccine requirements.⁵¹ Immunization records of nearly 950,000 children aged 11 and 12 years from the Arizona State Immunization System from 2007 to 2008 were analyzed in a 2013 study to illustrate the effects on meningococcal vaccine uptake following the implementation of a 2008 school-entry vaccine requirement for children entering the 6th grade. Results showed that adolescent meningococcal immunization rates in Arizona significantly increased (P < .0001) after the implementation of the vaccine requirement.⁵¹ Among children aged 11 years, vaccination rates increased from 20.1% to 48.2% from the 2006-2007 school year to the 2007-2008 school year. Among 12-year-olds, rates increased from 21% to 40.3%.⁵¹ Continuous monitoring and program feedback can drive iterative improvements, utilizing data to guide enhancements and recognize value.

Implications for Health Care Decision Makers

Inherent costs are associated with any intervention, and health care decision makers will require confirmation of cost-effectiveness and return on investment for continued program sustainability. There is an abundance of evidence to show that the economic burden of VPDs in the United States is staggering; in 2015 VPD costs among individuals 19 years and older were estimated at $9 billion (adjusted to $11.77 billion 2023 USD).^5,52 Almost 80% of the financial burden, or $7.1 billion, was attributed to unvaccinated individuals, underscoring the potential cost-savings of increasing vaccine uptake.⁵² Results of cost-effectiveness studies have consistently demonstrated the economic value of vaccination. The results of a 2022 meta-analysis on the cost-effectiveness of HPV vaccination delivery strategies showed an incremental cost-effectiveness ratio of approximately $79,000 per life years saved, a value that is within typically accepted willingness to pay thresholds in the United States.^53,54 HPV vaccination has been shown to significantly reduce the risk of most cervical cancers and other HPV-attributable cancers, preventing morbidity and mortality from HPV-related diseases and mitigating costs associated with treatment.^41,55 The results of a systematic review of influenza and pneumococcal vaccination studies conducted from 1980 to 2016 showed the majority of outcomes reported either cost-savings or cost-effectiveness ratios of $50,000 or less per quality-adjusted life year.⁵⁶ Because the financial benefits of vaccination programs may be seen in moderate- to long-term outcomes, continued studies demonstrating the economic value to health care decision makers are needed for stakeholder support.

Policy makers are tasked with incorporating innovative approaches into the decision-making process. To be successful, vaccine policies should follow a utilitarian doctrine to maximize the benefit to the greatest number of people within the target population while minimizing the burden on the individual.⁵⁷ Vaccine policy should be equitable and ensure no widening of current health disparities or mistrust in the health care system.⁵⁸ Limited research has been conducted on public health scaling and sustainment strategies.⁵⁹ More evidence is needed for consideration of the long-term sustainability of vaccination programs and integration into existing medical models.

Conclusions

By employing multifaceted strategies, innovative programs are of paramount importance in boosting vaccine uptake. These programs not only tailor messaging to resonate with diverse populations, dispelling misconceptions and countering vaccine hesitancy, but also introduce inventive approaches that increase accessibility in the community. By strategically placing vaccination services in potentially unconventional settings such as workplaces or community centers, they effectively remove logistical barriers that might deter individuals from seeking immunization. Innovative programs actively foster trust and credibility by engaging with community influencers and leveraging digital platforms to disseminate accurate information. This approach is especially vital in addressing disparities in vaccine uptake among different demographic groups, including marginalized populations, by building bridges of understanding and dispelling historic mistrust. Moreover, these programs are rooted in data-driven methodologies, continuously evaluating their impact and adapting strategies based on real-time feedback. This adaptability ensures that interventions remain responsive to evolving circumstances and preferences, maximizing their effectiveness over time.

Health care decision makers play a pivotal role in championing and implementing innovative approaches to enhance vaccine uptake. Their active support in allocating resources, advocating for policy changes, and fostering collaboration among stakeholders is instrumental in creating an environment conducive to the success of innovative vaccination programs. Health care decision makers are urged to prioritize the implementation of innovative programs. By recognizing the long-term benefits of increased immunization rates in preventing disease burdens and reducing health care costs, decision makers committed to innovative programs have the power to substantially enhance public health outcomes, reduce disease burden, and ensure a more resilient health care system for all.

Medical writing support provided by Libbi Green, PharmD.

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