Strategies for Success: Improving Influenza Vaccination Rates for Asthma within Pediatric Primary Care

Understanding Pediatric Asthma & Low Influenza Rates

According to the National Center for Health Statistics, 6.8 million children have asthma1,2 and asthma is the leading cause of morbidity and mortality in children.3 The rate of pediatric asthma diagnoses are increasing, and it is the most prevalent chronic disease in the United States. Asthma alters millions of children’s daily activities and is linked to a number of childhood disabilities. Influenza in patients with asthma increases the risk of asthma exacerbations, pneumonia, hospitalization, and death.5 The Centers for Disease Control and Prevention (CDC)5 have recommended that all children ages 6 months to 18 years with the diagnosis of asthma be immunized for influenza. Increasing influenza vaccination rates decreases exacerbations and improves the quality of life and wellbeing in children with asthma.

However, poor influenza vaccination rates among children with a chronic condition, like asthma, are common. According to Cooper and Walton-Moss, 6 influenza immunization rates for children with asthma are approximately less than 30%. Low immunization rates are multifactorial and involve both the patient and the clinician.7 According to the CDC’s Morbidity and Mortality Report,5 individuals with asthma had a 50% influenza vaccination rate for the 2010-2011 influenza season. Healthy People 2020 recommend increasing influenza vaccination rates for high- risk children to 80%.

A review of evidence and literature was completed to explore current information regarding the pediatric asthma population’s influenza vaccination rates, barriers to the influenza vaccine administration, and current interventions and recommendations.

Barriers Hindering Influenza Vaccine Administration

There are various factors which are important to identify that effect influenza vaccination rates: patient knowledge deficit of asthma and influenza virus; healthcare provider recommendations for the influenza vaccine; parental perspectives about the influenza virus and influenza vaccine; patient awareness regarding asthma risks associated with having the influenza infection; and patient interest in receiving the vaccine.7,8

Gnanasekaran et al.,9 identified modifiable factors influencing administration of influenza vaccination. The researchers reported that only 55% of the parents of children with asthma in their study recalled their provider recommending the influenza vaccination. The authors concluded that influenza vaccination rates for children with asthma are largely dependent on the caregiver’s knowledge; knowledge about the patient’s asthma, and the severity of his or her chronic condition; knowledge concerning the influenza virus and its effects on children with asthma; and the influenza vaccine’s yearly recommendations and adverse effects. In addition, parental preference plays a key role in increasing influenza vaccine rates.9

Evidence-Based Practice Strategies

Britto et al10 recommended improving communication between clinicians and patients, utilization of electronic health record tracking system, and educational training to improve rates. Britto and colleagues10 also pointed out that following the use of current evidence-based guidelines and creating standardized screenings help identify reasons for inadequate vaccination. National guidelines advise giving the influenza vaccination for all children with asthma.11 Kuhn et al12 stated that providers underutilize recommendations in the National Heart, Lung, and Blood Institute’s (NHLBI) asthma guidelines and do not consistently follow the stepwise approach in managing asthma. Influenza prevention and vaccination in this pediatric population is crucial in preventing further asthma complications and exacerbations.

A systematic review of 17 studies by Aigbogun et al13 evaluated specific interventions in children with asthma. Aigbogun et al13 aimed to identify, describe, and compare studies that examined interventions to improve influenza vaccination in children with chronic health conditions. This systematic review included seven randomized controlled trials, six before-and-after studies, one nonrandomized control trial, one retrospective cohort study, one quasi-experimental post-test study, and one letter to editors. The purpose of these studies was to examine different interventions to increase influenza vaccination rates in the pediatric asthma population, including multi-component strategies, letter reminders, telephone recall, letter plus telephone call, asthma educational tool and electronic health record (EHR), letter plus influenza clinics on Saturday, clinician screen alerts, and year-round appointments. According to the authors, the National Institute for Health and Care Excellence found that educating and training the healthcare team or provider-based interventions are effective in improving vaccination rates. The asthma educational tool for patients and the provider substantially raised vaccination rates in the pediatric asthma population.13

Cooper and Walton-Moss6 conducted a literature review of 11 articles consisting of randomized controlled trials, meta-analyses of randomized controlled trials, and quasi-experimental trials. The review found that improvements in influenza vaccination in children with asthma increased with the implementation of a reminder or recall system. One study in the review demonstrated that reminder letters to parents with a follow-up automated phone message encouraging influenza vaccination increased influenza vaccination rates from 5.4% to 32.1% in children from 6 months to 19 years of age.6 Cooper and Walton-Moss6 demonstrated the significant positive impact on rates when the healthcare clinician provided parental education about risks associated with acquiring the influenza infection. When the provider consciously included brief asthma and influenza immunization education at each sick and well child visit, the overall health in children with asthma improved and exacerbations decreased.

The Community Preventative Services Task Force14 performed a systematic review of 64 studies. Thirty-six of those studies identified methods that successfully increase vaccination rates within the healthcare setting. The review found strong quality evidence to support system-based interventions including the following: client reminder and recall systems, clinic-based client education, expanded access to health-care settings, provider assessment and feedback, provider reminders, and standing orders. The combination of two or more interventions could increase vaccine rates within targeted populations with the most commonly implemented interventions including provider reminder, provider education, and recall systems. The Community Preventative Services Task Force14 noted that when implemented effectively, a reminder system creates interaction between the primary care office and patient to improve immunization rates.


Current evidence-based educational materials from the CDC and the NHLBI on the importance of influenza prevention in pediatric asthma patients provide clinicians and patient/caregivers accurate information. Educational materials given to the patient should include the current CDC’s Vaccine Information Sheet (VIS) for the influenza vaccination.

As recommended by the CDC, implementation of a patient reminder system and educational strategies increase influenza vaccination rates in pediatric patients with asthma.13 A patient reminder system including a telephone call reminder to caregivers and postcard reminders encourage follow-up for the influenza vaccine. Various strategies such as provider education, recall reminder systems, and clinical decision support EHR alert identifiers for providers have also proven effective in increasing the influenza vaccination rates in this patient population.1 All providers should routinely assess their pediatric asthma patient’s influenza vaccination status, recommend the influenza vaccine, and provide influenza vaccination.15


  1. Simon A, Ahrenss K, Akinbami L Influenza vaccination among US children with asthma, 2005-2013. Acad Pediatr. 2016;16(1):68-74. doi:
  2. National Foundation for Infectious Disease Influenza and children with asthma: identifying and overcoming barriers to improved influenza immunization rates in high-risk populations. Bethesda, MA: NFID; 2008.
  3. Murphy E Improving influenza vaccination coverage in the pediatric asthma population: The case for combined methodologies. Yale J Biol Med. 2014;87:439-446. Accessed June 12, 2016.
  4. Akinbami L, Moorman J, Garbe P, Sondik E Status of childhood asthma in the United States, 1980-2007. Pediatr. 2009;123(3):s131-s145. doi: 10.1542/peds.2008-2233C
  5. Centers for Disease Control and Prevention Vaccination coverage among persons with asthma: Untied States, 2010-2011 influenza season. MMWR. 2013; 62(48): 973-978. Accessed June 12, 2016.
  6. Cooper S, Walton-Moss B (2013). Using reminder/recall systems to improve influenza immunization rates in children with asthma. Pediatric Healthcare. 2013;27(5):327-333. Accessed June 12, 2016.
  7. Santos-Sancho J, Lopez-de Andres A, Jimenez-Trujillo I et al Adherence and factors associated with influenza vaccination among subjects with asthma in Spain. Infect. 2013;41,465-471. doi:10.1007/s15010-0130414-2
  8. Vlahove, D, Bond, K, Jones, K, & Ompad, D Factors associated with differential uptake of seasonal influenza immunizations among underserved communities during the 2009-2010 influenza season. Community Health. 2012;37:282-287. doi10.1007/s10900-011-9443-x
  9. Gnanasekaran S, Finkelstein J, Hohman K, O’Brien M, Kruskal B, Lieu T Parental perspectives on influenza vaccination among children with asthma. Public Health Rep. 2006;121(2):181-188. Accessed June 14, 2016.
  10. Britto M, Schoettker P, Pandzik G, Weiland J, Mandel, K Improving influenza immunization for high-risk children and adolescents. Quality Safe Health Care. 2007;16:363-368. doi:10.1136/qshc.2006.019380
  11. Carol W, Burkimsher R Is there any evidence for influenza vaccination in children with asthma? Arch Dis Child. 2016;92(7):644-646. doi:10.1136/adc.2007.117085
  12. Kuhn L, Reeves K, Taylor Y et al, Planning for action: The impact of an asthma action plan decision tool integrated into an electronic health record (EHR) at a large health care system. J Am Board of Fam Med. 2015;28(3):382-393. doi:10.3122/jabfm.2015.03.140248
  13. Aigbogun N, Hawker J, Stewart, A Interventions to increase influenza vaccination rates in children with high-risk conditions- a systematic review. Science Direct. 2014;33:759-770. Accessed June 12, 2016.
  14. Community Preventative Services Task Force Increasing appropriate vaccination: healthcare system-based interventions implemented in combination. The Guide to Community Preventative Services. 2010. Accessed June 12, 2016.
  15. Centers for Disease Control and Prevention Healthcare professionals: Centers for Disease Control and Prevention: Asthma. Atlanta, GA; 2015. Accessed June 12, 2016.

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