Improving Adherence With Immunization Schedules

SupplementsFebruary 2018 Immunization Supplement
Volume 84
Issue 2

As a whole, adult vaccination coverage has remained unchanged without significant improvement.

View the PDF here.

Vaccination remains one of the most cost-effective interventions to reduce morbidity and mortality from vaccine-preventable diseases.1 Childhood immunization programs have increased the life expectancy during the 20th century and have helped to prevent 14 million cases of disease. National childhood vaccination rates remain high, and since the year 2000, government spending on vaccines and immunization have been increasing at a steady rate.2,3 Despite this progress, children are still at risk for vaccine-preventable diseases. In addition, adult vaccination coverage remains low for most routinely recommended vaccines and the prevalence of vaccine-preventable illnesses among older adults is notably high.4,5 To counteract this, the US Department of Health and Human Services has introduced Healthy People 2020, a nationwide health promotion and disease prevention program that includes goals for improving the immunization rates in the United States.2 Healthy People 2020 objectives and targets can be found on its website.

According to statistics from the CDC’s 2015 National Immunization Survey, the coverage for all vaccines among adults remained relatively low. However, the study did find modest gains in vaccination coverage for influenza in adults aged ≥19 years, pneumococcal in adults aged 19 to 64 years with increased risk, Tdap in adults aged ≥19 years, herpes zoster in adults aged ≥60 years, and hepatitis B in health care personnel aged ≥19 years of age. Nonetheless, even with these small gains, the rates are still well below the Healthy People 2020 goals. As a whole, adult vaccination coverage has remained unchanged without significant improvement.6


Almost 1 out of every 3 individuals in the United States will develop shingles, also known as herpes zoster.7 Shingles is caused by the reactivation of the varicella zoster virus, the same virus that causes chicken pox. The risk of getting shingles increases as you age, especially when your immune system loses the ability to suppress reactivation of the varicella zoster virus. Shingles typically presents as a painful, itchy rash that develops on 1 side of the body and can last for 2 to 4 weeks.8 Once the rash is gone, the most common complication of shingles is postherpetic neuralgia, which is severe pain in the areas where the shingles rash occurred. Postherpetic neuralgia causes substantial morbidity that can interfere with activities of daily living and reduce the quality of life.9 There are an estimated 1 million cases of shingles in the United States each year. Shingles is increasing among adults in the United States, and it remains unclear as to what is causing this increase.10 In 2015, 31% of adults aged 60 years and older reported receiving the shingles vaccine, which is an increase from the 28% reported the previous year. The increased prevalence of shingles reinforces the importance of continuing efforts to increase the vaccination rate among older adults.11

There are 2 vaccines for the prevention of herpes zoster. Zostavax (Merck & Co., Inc.), a live, attenuated vaccine, is licensed in the United States for the prevention of shingles in individuals 50 years of age and older and has been in the market since 2006.12 Zostavax is administered as a single subcutaneous injection. Shingrix (GlaxoSmithKline PLC) was recently approved by the FDA and is an inactivated, adjuvanted recombinant zoster vaccine denoted as HZ/su. HZ/su is administered intramuscularly (IM) in 2 doses (0.5 mL each) according to the following schedule: the first dose at month 0 followed by a second dose given anytime between 2 and 6 months later. After reconstituting Shingrix, it should be administered immediately or stored refrigerated and used within 6 hours.13 It is unknown how effective 1 dose of HZ/ su is, so completion of doses is crucial to ensure the expected protective immune response.14

Zostavax (ZVL, new CDC abbreviation) pre- and post-licensure show about a 51% reduction in shingles cases.15 In comparison in phase 3 trials, HZ/su showed 97.2% and 89.8% efficacy in those over 50 years and those over 70 years, respectively.13 The findings from these trials resulted in the Advisory Committee on Immunization Practices (ACIP) vote to recommend preferential use of Shingrix over Zostavax for all adults 50 years and older (ZVL is only ACIP routinely recommended for those 60 years and older). ACIP further recommended that healthy adults aged 50 years and older who had been previously vaccinated with Zostavax to now be vaccinated with Shingrix. These recommendations have been published in the Morbidity and Mortality Weekly Report.16 Other notable differences between HZ/ su and ZVL are that HZ/su is refrigerated instead of frozen and HZ/su appears to have a more sustained immune response.12,13 Since 2006, Zostavax has been the only vaccine in the market for the prevention of shingles. According to the CDC, vaccination rates for herpes zoster improved from 30.6% in 2013 to 34.2% in 2014.6 Even though Shingrix may have better efficacy than Zostavax, Shingrix is a 2-dose series vaccine with more adverse reactions, which may pose a new set of challenges when it comes to compliance with completing this vaccination series.


Adolescents and adults who receive only the first dose of a multi-series vaccine remain only partially protected from vaccine-related disease. It is not until they receive the final dose of the schedule that they will be protected.14 Completing the vaccine dose series within 1 year of the first dose has proven to be an obstacle in some settings. Most of the current literature has focused on evaluating the compliance and completion rates for human papillomavirus (HPV) vaccine. In 2015, coverage with ≥1 HPV vaccine dose was 49.8% and with ≥3 doses was 28.1% among males. Among females, coverage with ≥1 dose was 62.8% and with ≥3 doses was 41.9%.17 This indicates that there must be improved efforts focused on completing the additional required doses. For both cases, these vaccinations rates are far from the 2020 target of 80%,2 and many adolescents and young adults remain unprotected. Multiseries vaccinations completion may be hampered because it requires patients to come back to receive the additional doses. Improved systems of care need to be implemented to ensure every series of a vaccine that is started is finished. Providers and program planners should be aware that obtaining good initiation rates is not enough and efforts should be placed on the second or third vaccine.18


Taking advantage of visits to a health care provider and avoiding missed opportunities could help improve vaccine completion rates. A missed opportunity is a health care encounter in which a person is likely to receive a vaccination but is not vaccinated completely.19 Missed opportunities occur for several reasons: inability to screen patients for vaccination eligibility, perceived contraindications to vaccination, inconvenient clinic hours, and parental or community resistance to immunizations.20 Strategies to combat these common missed opportunities include identifying any person eligible for vaccination, incorporating immunization needs assessment into every clinical encounter21 and offering vaccinations to those who come into a health facility or pharmacy. One study showed that higher number of visits to a health care provider was associated with a 15% increased likelihood of HPV vaccine completion and a 4% to 6% increase in hepatitis B virus (HBV) vaccine completion.14


Understanding the barriers to immunization are necessary to develop interventions that effectively increase immunization coverage in both adolescents and adults. Some common obstacles that hinder vaccination rates include: lack of knowledge on which vaccines are recommended for adults and adolescents and misinformation about immunization on the internet and social media. Successful interventions include improving community awareness of services available and engaging with adults and health care providers in multiple settings.22

Pharmacists’ can act as a source of information to dispel misperceptions regarding vaccines and are able to identify patients at risk for vaccine-preventable diseases through use of pharmacy dispensing data and patient interviews. Pharmacists are also able to use an “inferred diagnosis” based on patient prescriptions when the medical record is not available, and identify specific populations at need for a specific vaccination. For example, a pharmacist that is dispensing medications indicated for diabetes to an adult patient should talk to the patient about possible need of the pneumococcal and hepatitis B vaccine. Other interventions that have led to an increase in the uptake of vaccinations among children, adolescents, and adults have been reminder interventions, such as contacting patients with a telephone call, letter or postcard in the mail, or electronic text message—with telephone reminders being the most effective. It was found that reminding patients to receive their vaccinations, can lead to an average of 8% increase in the number of people who get vaccinated.23

Other proposed solutions for pharmacists in the community is to collaborate with local health departments, health organizations, and provider offices to ensure completion of series vaccines that are started in these settings. For example, pharmacists can partner with obstetrician-gynecologists (OB-GYN) to have the OB-GYN administer the first dose of the HPV vaccine, and have the patient follow-up with the pharmacist to complete the remaining 2 doses in the pharmacy. This can be done for any vaccine that requires multiple doses for completion.


The recommendation from a health care provider is one of the most important predictors of patients uptake of vaccines. One study found that parents who receive a provider recommendation for vaccinations were more likely to have children who had completed the regimen.24 It is important for health care providers to encourage patients to vaccinate using dialogue-based interventions, which are considered most effective.25 Health care providers should routinely assess their patients for vaccination needs and provide a strong recommendation for any needed vaccines.

A strong and motivational recommendation should be tailored specifically for each individual and should address: (1) why the vaccine is recommended, (2) underscore consequences of the vaccine-preventable disease to the patient, and (3) benefits that are offered by the vaccine. The 2013 Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice is a useful document that provides other approaches that all health providers should incorporate into their routine immunization practice to increase vaccination coverage.26


Providing vaccinations outside of a traditional physician’s office in settings such as pharmacies offers opportunities for expanded access and convenience. In one study, providing immunization services during hours outside of traditional medical clinic hours allowed the working population to be vaccinated when it was convenient to them. The results of the study showed that about 30% of the study population received 1 or more vaccinations during these off-clinic hours.27

Aside from offering vaccinations at provider offices and pharmacies, some studies have even looked at vaccination completion rates when offered at schools. There is also strong evidence for high completion rates with school-delivery in high and low-middle income countries. For example, in a Canadian study, in-school HPV vaccination completion rates were 75% compared to 36% for those provided with a community-delivery model.28 This strengthens the need to create more access for community members to receive and complete their series vaccinations. Pharmacists can get involved in expanding access to immunizations by hosting vaccination clinics and events beyond the community pharmacy to other community settings such as schools, places of worship, colleges, malls, and workplaces.


As the pharmacists’ role continues to expand in immunization delivery, it will have a direct positive impact on the national efforts to increase immunization rates to the Healthy People 2020 goals.29 Pharmacists’ should follow the American Pharmacists Association’s Pharmacist Patient Care Process for Immunization Services which includes a systematic approach to collecting and assessing immunization information, planning for and implementing immunization administration; and follow-up and monitoring of series completion and safety.30 With more than 86% of Americans living within 5 miles of a community pharmacy, pharmacists are one of the most accessible, but underutilized health care providers in the US health care system.31

Amy Lei, PharmD, is a pharmacy resident at Kindred Hospital in La Mirada, California. She has no conflicts of interest to report.

Albert Bach, PharmD, is an assistant professor of pharmacy practice at Chapman University School of Pharmacy in Irvine, California, and faculty in residence at Newport Coast Pharmacy in Newport Beach, California. He has no conflicts of interest to report.

Jeff Goad, PharmD, MPH is a professor and the chair of the Department of Pharmacy Practice at Chapman University School of Pharmacy in Irvine, California. He is a speaker for Merck Vaccine and a consultant for GSK.


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2. Immunization and Infectious Disease. Healthy People 2020. Accessed 17 January 2018.

3. CDC. Vaccination Coverage Among Children in Kindergarten—United States, 2014-2015. MMWR Morb Mortal Wkly Rep. 2015;64:897-904

4. CDC. Estimates of deaths associated with seasonal influenza—United States, 1976—2007. MMWR Morb Mortal Wkly Rep. 2010;59:1057—62

5. Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United States. JAMA. 2004;292:1333—40

6. CDC. Surveillance of Vaccination Coverage Among Adult Populations—United States, 2015. MMWR Morb Mortal Wkly Rep; May 5, 2017;66(11);1—28

7. Hales CM, Harpaz R, Joesoef MR, Bialek SR. Examination of links between herpes zoster incidence and childhood varicella vaccination. Annals of Internal Medicine. 2013 159(11):739-45.

8. Cohen, J.I. (2013). Herpes zoster. N Engl J Med., 369, 255-263.

9. CDC. Prevention of herpes zoster: Recommendations of the advisory committee on immunization practices (ACIP). 2008/57(05); 1-30 Accessed 20 January 2018.

10. Shingles (Herpes Zoster) Vaccination Information for Healthcare Providers. Accessed 16 January 2018.

11. Leung J, Harpaz R, Molinari NA, Jumaan A, Zhou F. Herpes zoster incidence among insured persons in the United States, 1993-2006: evaluation of impact of varicella vaccination. Clinical Infectious Diseases. 2011;52(3):332-340.

12. ZOSTAVAX® (Zoster Vaccine Live) [Package Insert] Merck & Co., Inc. 2006 Accessed 18 January 2018.

13. SHINGRIX® (Zoster Vaccine Recombinant, Adjuvanted) [Package Insert] GlaxoSmithKline Biologicals. 2017. Accessed 18 January 2018.

14. Nelson JC, Bittner RC, Bounds L, et al. Compliance with multiple-dose vaccine schedules among older children, adolescents, and adults: results from a vaccine safety datalink study. Am J Public Health. 2009;99(Suppl 2):S389-S3897.

15. Oxman MN, Levin MJ, Johnson GR. A Vaccine to Prevent Herpes Zoster and Postherpetic Neuralgia in Older Adults. N Engl J Med. 2005; 352:2271-2284

16. Shingles (Herpes Zoster) Vaccination Information for Healthcare Providers. Accessed 16 January 2018.

17. CDC. Human papillomavirus vaccination coverage among adolescents, 2007-2013, and post licensure vaccine safety monitoring, 2006-2014—United States, MMWR Morb Mortal Wkly Rep 63(29);620-4.

18. Gallagher KE, Kadokura E, Miyake S, et al. Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review. BMC Public Health (2016). 16:172

19. Lee GM, et al. Adolescent immunizations: missed opportunities for prevention. Pediatrics. 2008;122(4):711—7. doi: 10.1542/peds.2007-2857.

20. Planning guide to reduce missed opportunities for vaccination. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO. Accessed 18 January 2018.

21. National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice. Public Health Reports. 2014. Volume 129

22. Briss PA, Rodewald LE, Hinman AR, et al; The Task Force on Community Preventive Services. Reviews of evidence regarding interventions to improve vaccination coverage in children, adolescents, and adults. Am J Prev Med. 2000;18(suppl 1):97—140

23. Jacobson Vann JC, Jacobson RM, Coyne-Beasley T, Asafu-Adjei JK, Szilagyi PG; Patient reminder and recall interventions to improve immunization rates. Cochrane Database Syst Rev. 2018 Jan 18;1:CD003941. doi: 10.1002/14651858.CD003941.pub3. [Epub ahead of print] Review. PubMed PMID: 29342498.

24. Gold R, Naleway A, Riedlinger K; Factors predicting completion of the human papillomavirus vaccine series. J Adolesc Health. 2013;52(4):427—32

25. Jarret C, Wilson R, O’Leary M et al.; Strategies for Addressing Vaccine Hesitancy-A Systematic Review. Vaccine. 33 (2015) 4180—4190.

26. National Vaccine Advisory Committee; Recommendations from the National Vaccine Advisory Committee: Standards for Adult Immunization Practice. Public Health Reports. 2014. Volume 129.

27. Goad JA, Taitel MS, Fensterbeim LE et al. Vaccinations administered during off-clinic hours at a national community pharmacy: implications for increasing patient access and convenience. Ann Fam Med. 2013; 429-436. Doi: 10.1370/afm.1542.

28. Sinka K et al. Achieving high and equitable coverage of adolescent HPV vaccine in Scotland. J Epidemiol Community Health. 2014;68(1):57—63.

29. Drozd, EM, Miller L, Johnsrud M. Impact of pharmacist immunization authority on seasonal influenza immunization rates across states. Clin Ther. 2017;39:1563—1580) & 2017

30. Bach A, Goad J, Rothholz M, et al. Applying the pharmacists’ patient care process to immunization services: a resource guide for pharmacists. American Pharmacists Association. Access 22 January 2018.

31. National Association of Chain Drug Stores (NACDS). 2011—2012 chain pharmacy industry profile. Alexandria, VA: NACDS, 2011.

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