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Emergency departments can also play an important role in providing influenza and pneumococcal immunizations, especially for people who have no other source of routine medical care. In two studies of emergency departments in university-affiliated hospitals, relatively little effort was required to raise the immunization rates. In one study of emergency department patients, 54% of unvaccinated patients were willing to be immunized when asked (Wrenn et al., 1994). In a second study, about half of elderly patients who were not vaccinated against influenza were vaccinated in the emergency department after receiving information about the vaccine (Rodriguez and Baroff, 1993).

Additional strategies for increasing vaccine use include community-based strategies. Compulsory immunization linked to school attendance has been the single most important strategy for ensuring high rates of childhood immunization among school-age children. School-based programs are also important for the delivery of adult vaccines. The American College Health Association now recommends that all students show records of receipt of vaccinations against measles, mumps, rubella, tetanus, and diphtheria. Some colleges have successfully implemented these recommendations by requiring such evidence before students enroll, before they are given grade reports, or before the transcripts of their records are issued.

Mass immunizations in settings where high-risk patients live have been particularly effective at delivering annual influenza immunizations. An underused approach is the use of Visiting Nurse Associations. Because of their contact with homebound elderly people, these nurses can effectively promote and administer the influenza vaccine. In one Canadian community-based study, public health nurses provided influenza vaccine to elderly people in their homes, at residences for senior citizens, and at well-advertised clinics (Sadoway et al., 1994). They accounted for 69% of the immunizations against influenza that were given, with an overall increase of 26% over the prior year. Potential immunization partnerships that have not been well studied include collaborations with pharmacists, chiropractors, and other health care providers who are outside the more traditional health care delivery systems.

Local health departments can play a major role in coordinating comprehensive efforts at immunizing at-risk populations. During the Medicare Influenza Demonstration Project in Rochester, New York, the Monroe County Health Department (MCHD) took responsibility for coordinating all aspects of vaccine distribution, promotion, and Medicare reimbursement (Bennett et al., 1994). For the duration of the project, proprietary nursing homes were given the option of holding open clinics, and vaccine was released to neighborhood health centers. Special urban outreach clinics were organized in churches, activity centers, and shopping malls. The coordinating role played by MCHD helped ensure that underserved and more vulnerable populations would have access to immunizations.

Encouraging Medicare beneficiaries to take advantage of preventive services is another important strategy. The most effective measures are personalized ones, such as a postcard reminder, particularly if the reminder is followed



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