1. Ottewell, Ashley MPH, CPH
  2. Martin, Kimberly MAT, BSN, RN
  3. Plescia, Marcus MD, MPH

Article Content

The COVID-19 vaccine has highlighted adult vaccination and vaccine hesitancy, particularly in communities of color. Prior to the COVID-19 pandemic, influenza, pneumonia, shingles, and hepatitis A and B vaccination rates were well below federal goals, with participation even lower across racial and ethnic groups.1,2 Key drivers of these rates include barriers to health care access, limited trust in the government and the medical establishment, as well as a lack of sufficient data to better understand racial and ethnic disparities. As we work to maximize COVID-19 vaccination and increase participation in routine adult vaccinations, we must be both strategic and cautious. In this column, we outline a summary of our adult immunization technical package of interventions for state and territorial health agencies (S/THA) to strengthen data management and improve adult vaccination.


ASTHO reviewed data on effective vaccination interventions that included an internal literature review of evidence-based approaches compiled by the Guide to Community Preventive Services, the US Preventive Services Task Force, and the Centers for Disease Control and Prevention. These evidence-based approaches were divided into 4 categories: community interventions, health care systems, data-driven strategies, and policy and regulatory approaches. On the basis of recent experience with the COVID-19 vaccination efforts, we prioritized 2 approaches ASTHO is well positioned to advocate for and assist or advise S/THA leaders with adult vaccination efforts:


1. Increasing vaccination efforts in community-based health care settings; and


2. Enhancing immunization information systems data sharing and reporting capacity.



Strengthen Partnerships With Community-Based Health Care Settings

Health care systems and medical providers are our traditional vaccination partners and are effective in addressing vaccine hesitancy on an individual level. Early in the COVID-19 vaccination effort, states channeled vaccine administration through high-volume community sites (ie, mass vaccination events). As demand for COVID-19 vaccine has decreased, many jurisdictions transitioned to increase vaccine administration in health care settings to better address vaccine hesitancy.


Community-based health care settings, such as Federally Qualified Health Centers (FQHCs), can help states understand barriers to vaccine uptake and implement focused and tailored strategies that address concerns and foster trust in communities of color. FQHCs receive most of their funding from designated federal grants and state Medicaid programs.3 They provide care to around 30 million medically underserved patients each year, with 63% of those patients belonging to a racial or ethnic minority group.4 During the pandemic, people of color made up the majority (64%) of those who received a COVID-19 vaccine in FQHCs.5 Working more closely with community-based health centers is an effective way for public health agencies to increase adult vaccination, particularly in underserved communities.


During the pandemic, FQHCs received direct allocations of COVID-19 vaccines from the federal government.6 Many states augmented FQHC vaccine supply with state allocations and engaged them in community outreach efforts. Some states also developed or expanded Medicaid reimbursement systems for vaccine counseling and administration. In the future, public health agencies can build on this momentum by continuing to work with FQHCs and networks, state primary care associations, and state Medicaid programs to expand clinical capacity and engage providers in a wide range of evidence-based practices to improve vaccination participation in health care settings.7 ASTHO and other national associations can work at the federal level to expand existing immunization benchmarks for children to include standardized adult vaccination measures and reimbursement systems that are recognized by the Health Resources & Services Administration, the National Committee for Quality Assistance, and the Centers for Medicare & Medicaid Services.


Enhancing Immunization Information Systems Data Reporting and Sharing Capacity

Perhaps, the greatest emerging challenge to increasing effective and equitable adult vaccination efforts is our lack of complete, interoperable data. As states enhance their immunization information systems (IISs), it is important to provide leadership on issues such as data exchange with clinical practice and to address our long-standing need to capture accurate and comprehensive data on race and ethnicity.


A number of states are now reporting more complete race and ethnicity data in their IISs. These improvements have required multiple strategies, including changes to existing laws barring the collection of federal reporting of race and ethnicity data; matching incomplete immunization data to electronic health records (EHRs), Health Information Exchange (HIE), and other data sets; state laws requiring providers to report race and ethnicity; incentives to encourage providers to improve collection and submission of these data; and widespread training of staff in both the public health and private health care workforce. Continued leadership on this issue as we implement data modernization efforts and expand the public health workforce could allow us to overcome a long-standing barrier to understanding and improving racial and ethnic health disparities for a wide range of public health issues beyond COVID-19.


Ultimately, IIS interoperability needs to be ubiquitous with the many other systems engaged across the immunization ecosystem, including EHRs, pharmacy systems, and HIEs, as well as other IISs. Interstate access to immunization records has been a long-standing challenge. However, many states are now addressing laws that prohibit IIS data sharing across borders, with multiple states working closely with HIEs and participating in the Immunization Gateway to increase interstate access to immunization records.8 In addition, state IISs could be more interoperable with health care providers. Most EHRs now upload vaccinations directly into the IISs, while also querying for information back to the practice for patients who have received vaccination elsewhere; ideally, this near-real time bidirectional data exchange would be available in every setting where immunization information was needed. Universal implementation of immunization data exchange with IISs would allow every provider to have immunization status on hand so that the right immunization can be given at the right time at every patient encounter. In parallel, IISs could work with HIEs or with larger health care system patient rosters to update this information on a regular basis so that practices can target patient outreach efforts.



Public health leaders are tasked with addressing many areas of public health and oftentimes have a short tenure to make an impact on the health of their state. Many public health agencies focus on improving vaccination rates because of the significant and avoidable human burden and cost of infectious disease. ASTHO's adult immunization technical package represents an approach to technical assistance at ASTHO that is evidence based, policy oriented, and proactive. It will be used as a guide to prioritize our technical assistance efforts with S/THA to address adult vaccination and demonstrate tangible health outcomes.




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2. Lu PJ, Hung MC, Srivastav A, et al Surveillance of vaccination coverage among adult populations-United States, 2018. MMWR Surveill Summ. 2021;70(SS-3):1-26. Accessed October 9, 2021. [Context Link]


3. Heisler EJ. Federal Health Centers: An Overview. Washington, DC: Congressional Research Service; 2017. Accessed October 9, 2021. [Context Link]


4. Health Resources & Services Administration. Ensuring equity in COVID-19 distribution. Accessed October 9, 2021. [Context Link]


5. Corallo B, Artiga S, Tolbert J; Kaiser Family Foundation. Are health centers facilitating equitable access to COVID-19 vaccinations? A June 2021 update. Published June 2, 2021. Accessed October 9, 2021. [Context Link]


6. Health Resources & Services Administration. Health Center Program: COVID-19 Frequently Asked Questions (FAQ). Accessed October 9, 2021. [Context Link]


7. Community Prevention Services Task Force. The Community Guide: CPSTF findings for increasing vaccination. Accessed October 9, 2021. [Context Link]


8. National Governors Association, Duke-Margolis Center for Health Policy, and COVID Collaborative. Supporting an equitable distribution of COVID-19 vaccines: key themes, strategies, and challenges across state and territorial COVID-19 vaccination plans. Published December 2020. Accessed October 9, 2021. [Context Link]