ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 4, NO. 6 ✦ NOVEMBER/DECEMBER 2006
Improving Infl uenza Vaccination Rates of
High-Risk Inner-City Children Over
2 Intervention Years
PURPOSE Infl uenza immunization rates among children with high-risk medical
conditions are disappointingly low, and relatively few data are available on rais-
ing rates, particularly over 2 years. We wanted to determine whether interven-
tions tailored to individual practice sites improve infl uenza immunization rates
among high-risk children in inner-city health centers over 2 years.
METHOD A before-after trial to improve infl uenza immunization of children
was conducted at 5 inner-city health centers (residencies and faith-based). Sites
selected interventions from a menu (eg, standing orders, patient and clinician
reminders, education) proved to increase vaccination rates, which were directed
at children aged 2 to 17 years with high-risk medical conditions. Intervention
infl uenza vaccination rates and 1 and 2 years were compared with those of the
preintervention year (2001-2002) and of a comparison site.
RESULTS Infl uenza vaccination rates improved modestly from baseline (10.4%)
to 13.1% during intervention year 1 and to 18.7% during intervention year 2 (P
<.001), with rates reaching 31% in faith-based practices. Rates increased in all
racial and age-groups and in Medicaid-insured children. The increase in rates was
signifi cantly greater in intervention health centers (8.3%) than in the comparison
health center (0.7%; P <.001). In regression analyses that controlled for demo-
graphic factors, vaccination status was associated with intervention year 1 (odds
ratio [OR], 1.9; 95% confi dence interval [CI], 1.6-2.2) and with intervention year
2 (OR, 2.8; 95% CI, 2.3-3.4), as well as with practice type. Adolescents had lower
vaccination rates than children 2 to 6 years old (OR, 0.6; 95% CI, 0.5-0.7).
CONCLUSIONS Tailored interventions selected from a menu of interventions mod-
estly increased infl uenza vaccination rates over 2 years at health centers serving
children from low-income families. We recommend this strategy for faith-based
practices and residencies with 1 practice site, but further research is needed on
multisite practices and to achieve higher infl uenza vaccination rates.
Ann Fam Med 2006;4:534-540. DOI: 10.1370/afm.612.
Pediatrics (AAP) recommend inactivated infl uenza vaccination for children
aged 6 months through 17 years with high-risk medical conditions1 -3 for
several reasons. First, children with high-risk medical conditions bear
a disproportionate share of the burden of hospitalizations and deaths
because of infl uenza.4 For instance, among children aged 1 to 4 years,
infl uenza-related hospitalization rates range from about 320 to 800 per
100,000 for those with high-risk conditions, compared with 86 to 186 per
100,000 for similarly aged healthy children.1,5,6 Second, because infl uenza
he Advisory Committee on Immunization Practices (ACIP) of the
Centers for Disease Control and Prevention, the American Acad-
emy of Family Physicians (AAFP), and the American Academy of
Richard K. Zimmerman, MD1,2
Alejandro Hoberman, MD3
Mary Patricia Nowalk, PhD, RD1
Chyongchiou J. Lin, PhD4,5
David P. Greenberg, MD3
Stuart T. Weinberg, MD6
Feng Shou Ko, MS7
Dwight E. Fox, DMD1
1Department of Family Medicine and Clini-
cal Epidemiology, University of Pittsburgh
School of Medicine, Pittsburgh, Pa
2Department of Behavioral and Community
Health Sciences, University of Pittsburgh
Graduate School of Public Health, Pitts-
3Department of Pediatrics, University
of Pittsburgh School of Medicine, Pitts-
4Department of Radiation Oncology, Uni-
versity of Pittsburgh School of Medicine,
5Department of Health Policy and Manage-
ment, University of Pittsburgh Graduate
School of Public Health, Pittsburgh, Pa
6Vanderbilt University, Nashville, Tenn
7Department of Biostatistics, University
of Pittsburgh Graduate School of Public
Health, Pittsburgh, Pa
Confl icts of interest: At the time of study design and
implementation, Dr. Greenberg was an employee of
the University of Pittsburgh; from the time of manu-
script preparation, he has been employed by Sanofi
Mary Patricia Nowalk, PhD, RD
Department of Family Medicine and
University of Pittsburgh School of Medicine
3518 Fifth Ave
Pittsburgh, PA 15261
ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 4, NO. 6 ✦ NOVEMBER/DECEMBER 2006
IMPROVING INFLUENZA VACCINATION
years, not just 1 year as is more typically reported in the
medical literature. During those 2 years, interventions
were tailored and refi ned to suit the capacities of the
individual centers. Clinically meaningful and statistically
signifi cant, but variable, increases in rates occurred. This
real-world experience occurred during a time of many
transitions that were unrelated to our study but that may
have diverted attention from the administration and
documentation of infl uenza immunization.
A limitation is the design as a before and after inter-
vention with a concurrent comparison group instead of
a randomized trial. Another limitation is the moderate
level of racial and other demographic data, which was
the result of our dependence on administrative data sets
from the health centers dictated by Health Insurance
Portability and Accountability Act; we had no control
over the completeness of such data.26
Tailored interventions modestly raise infl uenza
immunization rates over 2 years for children aged 2 to
17 years who have high-risk medical conditions. Con-
tinual refi nement of the strategies based on success of
these interventions and attention to individual offi ce
culture may help to further improve rates.
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/4/6/534.
Key words: Infl uenza vaccines; health services research; immunizations/
in infancy and childhood; infectious diseases
Submitted August 31, 2005; submitted, revised, February 13, 2006;
accepted March 4, 2006.
Funding support: This study was made possible through a cooperative
agreement between the Centers for Disease Control and Prevention and
the Association of Teachers of Preventive Medicine, award number TS-
894; and the EXPORT Health Project at the Center for Minority Health,
University of Pittsburgh Graduate School of Public Health, NIH/NCMHC
grant No. P60 MD-000-207.
Disclaimer: The contents of this report are the responsibility of the
authors and do not necessarily refl ect the offi cial views of the Centers
for Disease Control and Prevention, the Association of Teachers of Pre-
ventive Medicine, or the Center for Minority Health.
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