SHORT REPORT Human Vaccines & Immunotherapeutics 11:12, 2827--2830; December 2015; © 2015 Taylor & Francis Group, LLC
Acceptance of intradermal inactivated influenza vaccines among hospital staff following 2 seasonal vaccination campaigns Laura Goodliffe1, Brenda L Coleman1,2,*, Allison J McGeer2,3, and The Department of Occupational Health Wellness and Safety3 1
Infectious Disease Epidemiology Research Unit; Mount Sinai Hospital; Toronto, Ontario, Canada; 2Dalla Lana School of Public Health; University of Toronto; Toronto, Ontario, Canada; 3Infection Prevention and Control; Mount Sinai Hospital; Toronto, Ontario, Canada
Keywords: hospital, healthcare, influenza vaccines, immunization program, intradermal, pain perception
After a Canadian hospital’s official influenza vaccination campaign concluded in the 2011–2012 and 2012–2013 influenza seasons, study nurses provided additional vaccination mobile cart hours and the added choice of an intradermal injection. An additional 2.1% of staff in the first and 1.4% in the second season were vaccinated during the study with 90–99% preferring the intradermal injection or having no preference. All 13 staff who attempted selfinjection with the intradermal vaccine in 2012–2013 were successful on their first attempt. Offering alternatives to intramuscular vaccines may increase rates of vaccination.
Introduction
Results
Influenza causes 250,000 to 500,000 deaths annually world-wide.1 Influenza vaccination has been shown to reduce illness and mortality, with vaccine effectiveness estimated at approximately 60% for adults 18 to 64 y of age.2 Vaccinating healthcare workers helps protect coworkers, families, and patients, many of whom are at increased risk of developing complications from influenza infection.3 However, vaccine uptake among healthcare workers when relying on voluntary participation remains less than optimal.4,5 Intradermal injection of influenza vaccines may increase vaccine uptake since IntanzaÒ , for example, uses a much smaller needle (30 gauge, 1.5 mm), less antigen per strain (9 mg for younger adults), and less total volume (0.1 mL).6 Compared with intramuscular formulations, intradermal influenza vaccines induce non-inferior immune responses in healthy adults and are less likely to induce muscle soreness but are more likely to induce injection site irritation (redness, swelling, itching).6-9 The objectives of this study were to assess the rates of staff vaccination, determine whether offering a supplemental mobile vaccination cart with a choice of intradermal (ID) or intramuscular (IM) vaccines increased vaccine uptake, and to determine the relative acceptability of ID and IM administration of influenza vaccine for healthcare workers who were unvaccinated after the end of a hospital influenza vaccination campaign.
2011–2012 influenza season Staff coverage reached 46.6% by the end of the hospital vaccination campaign but varied from 44.2% of 4404 payroll employees and 43.2% of 470 volunteers to 86.3% of 277 non-staff physicians, physicians with admitting privileges, but not on the hospital payroll (P < 0.001). Following the campaign, 452 unvaccinated staff were approached by a study nurse, of whom 108 (24%) accepted vaccination, increasing coverage to 48.7%. Eighty staff received the ID injection, including 4 who initially refused any vaccination and 11 who had never previously been vaccinated against influenza. Neither sex nor occupation was associated with choice of ID versus IM injection. Prior to vaccination, 41/77 (53%) of the ID recipients (96% response rate) stated that they don’t mind needles/injections, 31% dislike the needle of the IM injection, but not enough to delay vaccination, 13% dislike it enough to avoid it for a few days, and one respondent reported never having been vaccinated because s/he was too afraid of needles (see Table 1). Of the 33 who disliked the needle and responded, 15 (45%) worried about a sore arm, 33% disliked the pain of injection, and 15% most disliked the thought of the needle. The mean rating of recalled pain of previous influenza vaccine injection (3.3 [95% CI: 3.1–3.5]) was similar to that reported following ID injection (2.9 [95% CI: 2.6–3.1]; P D .38). Fifty-nine percent stated they would choose the ID injection for future vaccinations (32% had no preference).
*Correspondence to: Brenda L Coleman; Email: [email protected] Submitted: 03/12/2015; Revised: 06/24/2015; Accepted: 07/08/2015 http://dx.doi.org/10.1080/21645515.2015.1072665
www.tandfonline.com
Human Vaccines & Immunotherapeutics
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Table 1. Participants vaccinated with intradermal influenza vaccine after hospital influenza immunization campaign completed, Toronto, Canada 2011–12
2012–13
P-value
41/77 (53.2) 24 (31.2) 10 (13.0) 2 (2.6)
33/59 (55.9) 20 (33.9) 1 (1.7) 5 (8.5)
NS
15/33 (45.4) 11 (33.3) 5 (15.1) 2 (6.0)
7/24 (29.2) 13 (54.2) 4 (16.7) 0
NS
44/75 (58.7) 24 (32.0) 7 (9.3) 3.3 (3.1–3.5) 2.9 (2.6–3.1)
47/59 (79.7) 11 (18.6) 1 (1.7) 3.9 (3.6–4.2) 2.3 (2.1–2.5)
0.02
1
Feel about needle for vaccine Don’t mind Mind, but don’t hesitate Mind, defer a few days Must force self/phobic If dislike, dislike most about needle1 Sore arm afterwards Pain of injection Thought of needle into skin Other (vaccine/reaction to it) Preference if offered ID or IM next year2 Intradermal No preference Intramuscular Mean recalled pain from IM1 (0–10; n D 71 & 51) Mean pain of ID2 (0–10; n D 77 & 59)
NS NS
1Pre-injection questionnaire; 2Post-injection questionnaire. ID: intradermal; IM: intramuscular.
2012–2013 influenza season The hospital campaign vaccinated 51.8% of hospital staff with non-staff physicians more likely (83.3% of 312) to be vaccinated than 4409 payroll employees (50.2%) or 541 volunteers (46.6%; P < .0001). Following the hospital campaign, study nurses approached 951 staff, 332 of whom were as-yet unvaccinated. Nine people received the IM injection, 51 the nurse-administered ID, and 13 the self-administered ID vaccine increasing coverage to 53.2%. All self-administrations were successful on the first attempt. Choice of route of administration was not associated with sex or occupation. Nine staff who had never previously been vaccinated for influenza accepted the ID vaccine, including one person who self-administered the vaccine. Prior to vaccination, 6/59 (10%) respondents receiving the ID vaccine (96% response rate) stated that they disliked the IM needle enough to avoid it for a few days, 7% (n D 4) were afraid of needles and had to force themselves to be vaccinated, and 1 person had never been vaccinated because s/he was too afraid of needles. Of those who disliked the needle and responded (N D 24), 29% worried about a sore arm, 54% disliked the pain of injection, and 17% most disliked the thought of the needle into their skin. The mean rating of pain recalled from previous influenza vaccine injections (3.9 [95% CI: 3.6–4.2]) was significantly higher than the injection pain rating of the nurse-administered (2.5 [95% CI: 1.9–3.0]; P < .001) or self-administered (1.7 [95% CI: 1.0–2.4]; P < .001) ID vaccine. The reported pain of nurse-administered and self-administered ID vaccines were similar (P D .18). Eighty percent who received the ID injection would choose it again in future while 19% had no preference of ID or IM. All of those who self-administered (N D 13) were either very (N D 7) or somewhat (N D 6) sure that they administered it correctly, 12 of 13 were willing to do so again in the future and would choose nurse guidance in a group (N D 4) or one-on-one
2828
(N D 5) setting, written guidance, nurse-administered, or had no preference (N D 1each).
Discussion There was an increase in the reported rate of staff vaccination with seasonal influenza vaccine from 2011–12 to 2012–13 which was likely largely attributable to the increased effort to collect vaccination status forms and the introduction of influenza vaccine champions, which have been shown to increase coverage rates by 15–24% and 11–20%, respectively.10-13 Even with increased efforts in our hospital, the vaccination status of over 40% of staff remained unknown at the end of the 2012–2013 campaign. During both seasons under study, extending the availability of the mobile vaccination cart and offering the ID vaccine resulted in a modest increase in vaccination coverage (1.4– 2.1%). Over 20% of the unvaccinated staff approached by study nurses accepted a vaccine, including 20 people who had never previously been vaccinated against influenza. What portion of the increase was due to directly approaching the staff or was due to offering a choice of an ID injection is unknown. Since over half of the study participants (all of whom were unvaccinated at the end of the hospital campaign) said that getting a needle does not bother them at all, it is likely that approaching them directly was responsible for their uptake. Offering the ID injection may have enticed about 20% of participants: those who stated that the anticipated pain or the thought/angst of injection was the thing they most disliked about receiving their influenza vaccine.14 It is also possible that offering healthcare workers a choice between 2 vaccine delivery systems provides them with a sense of autonomy and choice. However, a cluster-randomized trial of offering intranasal or IM vaccines to non-healthcare employees found no difference in overall uptake of the influenza vaccine without intensified advertising.15
Human Vaccines & Immunotherapeutics
Volume 11 Issue 12
As seen in other studies,7,16-18 acceptance of the ID injection was high in both seasons, with 74% and 89% of healthcare workers who accepted vaccine choosing it. About 20% of people in the second influenza season agreed to try the nurse-guided selfadministration of the ID vaccine, all of whom were successful on their first attempt which is similar to the 93–100% success rate for self-administration of the ID vaccine in earlier studies at this site.7 (and unpublished data) This study is limited by the number of changes to the influenza vaccination program making it impossible to attribute increases in coverage to a specific component of the program. Since the ID vaccines were only offered after the hospital immunization campaign was complete, we cannot extrapolate the impact of offering choices during a campaign or on whether acceptance of an ID vaccine would be as high if offered earlier in the campaign. Also, because the ID vaccine was only offered through the study, the participants were volunteers, injections were based on choice, and the number of study subjects was low (N D 181), we are unable to generalize the findings to all staff. However, ID vaccines are accepted by adults who are apprehensive about IM injections and the level of acceptance is high in a variety of settings.7,16-18 Further studies of more rigorous design are needed to determine the potential impact of offering ID vaccines to hospital staff. This study demonstrated acceptance of the ID vaccine among healthcare staff, many of whom reported a preference for this route in future seasons. Also, offering the influenza vaccine through a mobile immunization cart marginally increased influenza vaccination coverage.
Methods Study population Mount Sinai Hospital is a 427-bed academic acute care hospital in Toronto, Canada with approximately 5,000 staff. Studies were approved by the hospital research ethics board and conducted according to the Tri-Council Policy Statement. 2011–2012 influenza season Intramuscular trivalent, inactivated vaccine was available, free of charge, at various times and locations throughout the hospital for staff and students. The vaccination campaign had support from senior leadership including modeling vaccine receipt, providing resources, and policy implementation, and was advertised using a variety of internal media with a corporate target of 53% for the season. The vaccination campaign lasted from October 17–28, 2011 with both stationary clinics and mobile carts available Monday through Friday from 0700–1430 along with 4 evening clinics. Four weekend clinics and mobile vaccination carts offered vaccine during November. References 1. World Health Organization. Influenza (seasonal). World Health Organization; Geneva, Switzerland 2014. 2. Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis
www.tandfonline.com
From December 19, 2011 to February 3, 2012, study nurses provided vaccine with a mobile influenza vaccination cart during daytime, evening, and weekend hours. Staff were approached, and if unvaccinated, given a brief description of ID vaccine (IntanzaÒ ) and vaccinated according to their preference of IM or ID vaccine. Those choosing the ID injection were asked to complete paper-based questionnaires prior to and immediately following injection that asked about prior vaccination history, level of unease due to needles, and perceived pain of injection. 2012–2013 influenza season Clinics took place October 15–21 and October 29-November 4, 2012. Vaccine was available in the same areas and times as in the 2011–2012 campaign. Four changes were made compared with the previous year: 1) the corporate target was increased to 61%, 2) influenza vaccination champions were introduced who advocated for vaccination through education, advocacy, levering relationships, and negotiating professional boundaries, 3) managers followed up with more staff to complete vaccination/declination forms, and 4) unit-level coverage was reported to unit managers. From December 19th 2012 to January 21st 2013, study nurses offered 3 choices of influenza vaccine through the mobile influenza vaccination cart: self-administered ID, nurse-administered ID, or nurse-administered IM. A trained study nurse demonstrated and verbally instructed the healthcare worker using a dummy injection device. Successful self-administration was defined as safely administering the full dose of ID vaccine on the first attempt. All ID vaccine recipients were asked to complete questionnaires. Statistical analyses Descriptive statistical methods were used to calculate vaccination coverage rates and paired t tests were used to compare recalled and actual pain of injection using SAS (SAS Institute, Cary, NC).
Disclosure of Potential Conflicts of Interest
McGeer AJ received a grant received for investigator-initiated study from Sanofi Pasteur. Funding
Sanofi Pasteur provided funding for this investigator-initiated trial and approved the protocol. The study protocol was written by the investigators who were solely responsible for the conduct of the trial, collection and analysis of data, interpretation of results, and preparation of the manuscript.
2012; 12:36-44; PMID:22032844; http://dx.doi.org/ 10.1016/S1473-3099(11)70295-X 3. Weinstock DM, Eagan J, Malak SA, Rogers M, Wallace H, Kiehn TE, Sepkowitz KA. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol 2000; 21:730-2; PMID:11089659; http://dx.doi.org/10.1086/501726
Human Vaccines & Immunotherapeutics
4. Mereckiene J, Cotter S, Nicoll A, Levy-Bruhl D, Ferro A, Tridente G, Zanoni G, Berra P, Salmaso S, O’Flanagan D, et al. National seasonal influenza vaccination survey in Europe, 2008. Euro Surveill 2008; 13:19017; PMID:18947524 5. US Department of Health and Human Services. Healthy People 2020 Objectives for Healthcare
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6. 7.
8.
9.
Personnel: IID-12.9. Washington, DC: US Government; 2010. Pasteur S. IntanzaÒ influenza vaccine (split virion, inactivated). Toronto, Canada; 2012:31. Coleman BL, McGeer AJ, Halperin SA, Langley JM, Shamout Y, Taddio A, Shah V, McNeil SA. A randomized control trial comparing immunogenicity, safety, and preference for self- versus nurse-administered intradermal influenza vaccine. Vaccine 2012; 30:6287-93; PMID:22902784; http://dx.doi.org/10.1016/j. vaccine.2012.08.006 Hoon Han S, Hee Woo J, Weber F, Joo Kim W, Ran Peck K, Il Kim S, Hwa Choi Y, Myung Kim J. Immunogenicity and safety of IntanzaÒ /IDfluÒ intradermal influenza vaccine in South Korean adults: a multicenter, randomized trial. Human Vaccines and Immunotherapeutics 2013; 9:1971-7; PMID:23778938; http:// dx.doi.org/10.4161/hv.25295 Beran J, Ambrozaitis A, Laiskonis A, Mickuviene N, Bacart P, Calozet Y, Demanet E, Heijmans S, Van Belle P, Weber F, et al. Intradermal influenza vaccination of healthy adults using a new microinjection system: a 3-year randomised controlled safety and immunogenicity trial. BMC Medicine 2009; 7:13; PMID:19341446; http://dx.doi.org/10.1186/17417015-7-13
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10. Ribner BS, Hall C, Steinberg JP, Bornstein WA, Chakkalakal R, Emamifar A, Eichel I, Lee PC, Castellano PZ, Grossman GD. Use of a mandatory declination form in a program for influenza vaccination of healthcare workers. Infection Control Hospital Epidemiology 2008; 29:302-8; PMID:18462141; http://dx.doi.org/ 10.1086/529586 11. Bertin M, Scarpelli M, Proctor AW, Sharp J, Robitson E, Donnelly T, Young C, Gordon SM. Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program. Am J Infect Control 2007; 35:33-7; PMID:17276789; http://dx.doi.org/10.1016/j. ajic.2006.10.005 12. Kimura AC, Higa JI, Nguyen C, Vugia DJ, Dysart M, Ellingson L, Chelstrom L, Thurn J, Nichol KL, Poland GA, et al. Interventions to increase influenza vaccination of health-care workers–California and Minnesota. MMWR Morb Mortal Wkly Rep 2005; 54:196-9; PMID:15744227 13. Slaunwhite JM, Smith SM, Fleming MT, Strang R, Lockhart C. Increasing vaccination rates among health care workers using unit “champions” as a motivator. Can J Infect Control 2009; 24:159-64; PMID:19891169
Human Vaccines & Immunotherapeutics
14. Lambert PH, Laurent PE. Intradermal vaccine delivery: will new delivery systems transform vaccine administration? Vaccine 2008; 26:3197-208; PMID:18486285; http://dx.doi.org/10.1016/j.vaccine.2008.03.095 15. Nowalk MP, Lin CJ, Toback SL, Rousculp MD, Eby C, Raymund M, Zimmerman RK. Improving influenza vaccination rates in the workplace: a randomized trial. Am J Prev Med 2010; 38:237-46; PMID:20036102; http://dx.doi.org/10.1016/j.amepre.2009.11.011 16. Dhont PA, Albert A, Brenders P, Podwapinska A, Pollet A, Scheveneels D, Tihon F, Verheyden I, Victor J, Samson SI. Acceptability of IntanzaÒ 15 mcg intradermal influenza vaccine in Belgium during the 2010-2011 influenza season. Adv Ther 2012; 29:562-77; PMID:22678831; http://dx. doi.org/10.1007/s12325-012-0025-9 17. Eizenberg P, Booy R, Naser N, Mason G, Stamboulian D, Weber F. Acceptance of IntanzaÒ 9 mg intradermal influenza vaccine in routine clinical practice in Australia and Argentina. Advances in Therapy 2011; 28:640-9; PMID:21751080; http://dx.doi.org/10.1007/s12325011-0042-0 18. Prymula R, Usluer G, Altinel S, Sichova R, Weber F. Acceptance and opinions of Intanza/IDflu intradermal influenza vaccine in the Czech Republic and Turkey. Adv Ther 2012; 29:41-52; PMID:22228256; http:// dx.doi.org/10.1007/s12325-011-0090-5
Volume 11 Issue 12
Acceptance of intradermal inactivated influenza vaccines among hospital staff following 2 seasonal vaccination campaigns Laura Goodliffe1, Brenda L Coleman1,2,*, Allison J McGeer2,3, and The Department of Occupational Health Wellness and Safety3 1
Infectious Disease Epidemiology Research Unit; Mount Sinai Hospital; Toronto, Ontario, Canada; 2Dalla Lana School of Public Health; University of Toronto; Toronto, Ontario, Canada; 3Infection Prevention and Control; Mount Sinai Hospital; Toronto, Ontario, Canada
Keywords: hospital, healthcare, influenza vaccines, immunization program, intradermal, pain perception
After a Canadian hospital’s official influenza vaccination campaign concluded in the 2011–2012 and 2012–2013 influenza seasons, study nurses provided additional vaccination mobile cart hours and the added choice of an intradermal injection. An additional 2.1% of staff in the first and 1.4% in the second season were vaccinated during the study with 90–99% preferring the intradermal injection or having no preference. All 13 staff who attempted selfinjection with the intradermal vaccine in 2012–2013 were successful on their first attempt. Offering alternatives to intramuscular vaccines may increase rates of vaccination.
Introduction
Results
Influenza causes 250,000 to 500,000 deaths annually world-wide.1 Influenza vaccination has been shown to reduce illness and mortality, with vaccine effectiveness estimated at approximately 60% for adults 18 to 64 y of age.2 Vaccinating healthcare workers helps protect coworkers, families, and patients, many of whom are at increased risk of developing complications from influenza infection.3 However, vaccine uptake among healthcare workers when relying on voluntary participation remains less than optimal.4,5 Intradermal injection of influenza vaccines may increase vaccine uptake since IntanzaÒ , for example, uses a much smaller needle (30 gauge, 1.5 mm), less antigen per strain (9 mg for younger adults), and less total volume (0.1 mL).6 Compared with intramuscular formulations, intradermal influenza vaccines induce non-inferior immune responses in healthy adults and are less likely to induce muscle soreness but are more likely to induce injection site irritation (redness, swelling, itching).6-9 The objectives of this study were to assess the rates of staff vaccination, determine whether offering a supplemental mobile vaccination cart with a choice of intradermal (ID) or intramuscular (IM) vaccines increased vaccine uptake, and to determine the relative acceptability of ID and IM administration of influenza vaccine for healthcare workers who were unvaccinated after the end of a hospital influenza vaccination campaign.
2011–2012 influenza season Staff coverage reached 46.6% by the end of the hospital vaccination campaign but varied from 44.2% of 4404 payroll employees and 43.2% of 470 volunteers to 86.3% of 277 non-staff physicians, physicians with admitting privileges, but not on the hospital payroll (P < 0.001). Following the campaign, 452 unvaccinated staff were approached by a study nurse, of whom 108 (24%) accepted vaccination, increasing coverage to 48.7%. Eighty staff received the ID injection, including 4 who initially refused any vaccination and 11 who had never previously been vaccinated against influenza. Neither sex nor occupation was associated with choice of ID versus IM injection. Prior to vaccination, 41/77 (53%) of the ID recipients (96% response rate) stated that they don’t mind needles/injections, 31% dislike the needle of the IM injection, but not enough to delay vaccination, 13% dislike it enough to avoid it for a few days, and one respondent reported never having been vaccinated because s/he was too afraid of needles (see Table 1). Of the 33 who disliked the needle and responded, 15 (45%) worried about a sore arm, 33% disliked the pain of injection, and 15% most disliked the thought of the needle. The mean rating of recalled pain of previous influenza vaccine injection (3.3 [95% CI: 3.1–3.5]) was similar to that reported following ID injection (2.9 [95% CI: 2.6–3.1]; P D .38). Fifty-nine percent stated they would choose the ID injection for future vaccinations (32% had no preference).
*Correspondence to: Brenda L Coleman; Email: [email protected] Submitted: 03/12/2015; Revised: 06/24/2015; Accepted: 07/08/2015 http://dx.doi.org/10.1080/21645515.2015.1072665
www.tandfonline.com
Human Vaccines & Immunotherapeutics
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Table 1. Participants vaccinated with intradermal influenza vaccine after hospital influenza immunization campaign completed, Toronto, Canada 2011–12
2012–13
P-value
41/77 (53.2) 24 (31.2) 10 (13.0) 2 (2.6)
33/59 (55.9) 20 (33.9) 1 (1.7) 5 (8.5)
NS
15/33 (45.4) 11 (33.3) 5 (15.1) 2 (6.0)
7/24 (29.2) 13 (54.2) 4 (16.7) 0
NS
44/75 (58.7) 24 (32.0) 7 (9.3) 3.3 (3.1–3.5) 2.9 (2.6–3.1)
47/59 (79.7) 11 (18.6) 1 (1.7) 3.9 (3.6–4.2) 2.3 (2.1–2.5)
0.02
1
Feel about needle for vaccine Don’t mind Mind, but don’t hesitate Mind, defer a few days Must force self/phobic If dislike, dislike most about needle1 Sore arm afterwards Pain of injection Thought of needle into skin Other (vaccine/reaction to it) Preference if offered ID or IM next year2 Intradermal No preference Intramuscular Mean recalled pain from IM1 (0–10; n D 71 & 51) Mean pain of ID2 (0–10; n D 77 & 59)
NS NS
1Pre-injection questionnaire; 2Post-injection questionnaire. ID: intradermal; IM: intramuscular.
2012–2013 influenza season The hospital campaign vaccinated 51.8% of hospital staff with non-staff physicians more likely (83.3% of 312) to be vaccinated than 4409 payroll employees (50.2%) or 541 volunteers (46.6%; P < .0001). Following the hospital campaign, study nurses approached 951 staff, 332 of whom were as-yet unvaccinated. Nine people received the IM injection, 51 the nurse-administered ID, and 13 the self-administered ID vaccine increasing coverage to 53.2%. All self-administrations were successful on the first attempt. Choice of route of administration was not associated with sex or occupation. Nine staff who had never previously been vaccinated for influenza accepted the ID vaccine, including one person who self-administered the vaccine. Prior to vaccination, 6/59 (10%) respondents receiving the ID vaccine (96% response rate) stated that they disliked the IM needle enough to avoid it for a few days, 7% (n D 4) were afraid of needles and had to force themselves to be vaccinated, and 1 person had never been vaccinated because s/he was too afraid of needles. Of those who disliked the needle and responded (N D 24), 29% worried about a sore arm, 54% disliked the pain of injection, and 17% most disliked the thought of the needle into their skin. The mean rating of pain recalled from previous influenza vaccine injections (3.9 [95% CI: 3.6–4.2]) was significantly higher than the injection pain rating of the nurse-administered (2.5 [95% CI: 1.9–3.0]; P < .001) or self-administered (1.7 [95% CI: 1.0–2.4]; P < .001) ID vaccine. The reported pain of nurse-administered and self-administered ID vaccines were similar (P D .18). Eighty percent who received the ID injection would choose it again in future while 19% had no preference of ID or IM. All of those who self-administered (N D 13) were either very (N D 7) or somewhat (N D 6) sure that they administered it correctly, 12 of 13 were willing to do so again in the future and would choose nurse guidance in a group (N D 4) or one-on-one
2828
(N D 5) setting, written guidance, nurse-administered, or had no preference (N D 1each).
Discussion There was an increase in the reported rate of staff vaccination with seasonal influenza vaccine from 2011–12 to 2012–13 which was likely largely attributable to the increased effort to collect vaccination status forms and the introduction of influenza vaccine champions, which have been shown to increase coverage rates by 15–24% and 11–20%, respectively.10-13 Even with increased efforts in our hospital, the vaccination status of over 40% of staff remained unknown at the end of the 2012–2013 campaign. During both seasons under study, extending the availability of the mobile vaccination cart and offering the ID vaccine resulted in a modest increase in vaccination coverage (1.4– 2.1%). Over 20% of the unvaccinated staff approached by study nurses accepted a vaccine, including 20 people who had never previously been vaccinated against influenza. What portion of the increase was due to directly approaching the staff or was due to offering a choice of an ID injection is unknown. Since over half of the study participants (all of whom were unvaccinated at the end of the hospital campaign) said that getting a needle does not bother them at all, it is likely that approaching them directly was responsible for their uptake. Offering the ID injection may have enticed about 20% of participants: those who stated that the anticipated pain or the thought/angst of injection was the thing they most disliked about receiving their influenza vaccine.14 It is also possible that offering healthcare workers a choice between 2 vaccine delivery systems provides them with a sense of autonomy and choice. However, a cluster-randomized trial of offering intranasal or IM vaccines to non-healthcare employees found no difference in overall uptake of the influenza vaccine without intensified advertising.15
Human Vaccines & Immunotherapeutics
Volume 11 Issue 12
As seen in other studies,7,16-18 acceptance of the ID injection was high in both seasons, with 74% and 89% of healthcare workers who accepted vaccine choosing it. About 20% of people in the second influenza season agreed to try the nurse-guided selfadministration of the ID vaccine, all of whom were successful on their first attempt which is similar to the 93–100% success rate for self-administration of the ID vaccine in earlier studies at this site.7 (and unpublished data) This study is limited by the number of changes to the influenza vaccination program making it impossible to attribute increases in coverage to a specific component of the program. Since the ID vaccines were only offered after the hospital immunization campaign was complete, we cannot extrapolate the impact of offering choices during a campaign or on whether acceptance of an ID vaccine would be as high if offered earlier in the campaign. Also, because the ID vaccine was only offered through the study, the participants were volunteers, injections were based on choice, and the number of study subjects was low (N D 181), we are unable to generalize the findings to all staff. However, ID vaccines are accepted by adults who are apprehensive about IM injections and the level of acceptance is high in a variety of settings.7,16-18 Further studies of more rigorous design are needed to determine the potential impact of offering ID vaccines to hospital staff. This study demonstrated acceptance of the ID vaccine among healthcare staff, many of whom reported a preference for this route in future seasons. Also, offering the influenza vaccine through a mobile immunization cart marginally increased influenza vaccination coverage.
Methods Study population Mount Sinai Hospital is a 427-bed academic acute care hospital in Toronto, Canada with approximately 5,000 staff. Studies were approved by the hospital research ethics board and conducted according to the Tri-Council Policy Statement. 2011–2012 influenza season Intramuscular trivalent, inactivated vaccine was available, free of charge, at various times and locations throughout the hospital for staff and students. The vaccination campaign had support from senior leadership including modeling vaccine receipt, providing resources, and policy implementation, and was advertised using a variety of internal media with a corporate target of 53% for the season. The vaccination campaign lasted from October 17–28, 2011 with both stationary clinics and mobile carts available Monday through Friday from 0700–1430 along with 4 evening clinics. Four weekend clinics and mobile vaccination carts offered vaccine during November. References 1. World Health Organization. Influenza (seasonal). World Health Organization; Geneva, Switzerland 2014. 2. Osterholm MT, Kelley NS, Sommer A, Belongia EA. Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis. Lancet Infect Dis
www.tandfonline.com
From December 19, 2011 to February 3, 2012, study nurses provided vaccine with a mobile influenza vaccination cart during daytime, evening, and weekend hours. Staff were approached, and if unvaccinated, given a brief description of ID vaccine (IntanzaÒ ) and vaccinated according to their preference of IM or ID vaccine. Those choosing the ID injection were asked to complete paper-based questionnaires prior to and immediately following injection that asked about prior vaccination history, level of unease due to needles, and perceived pain of injection. 2012–2013 influenza season Clinics took place October 15–21 and October 29-November 4, 2012. Vaccine was available in the same areas and times as in the 2011–2012 campaign. Four changes were made compared with the previous year: 1) the corporate target was increased to 61%, 2) influenza vaccination champions were introduced who advocated for vaccination through education, advocacy, levering relationships, and negotiating professional boundaries, 3) managers followed up with more staff to complete vaccination/declination forms, and 4) unit-level coverage was reported to unit managers. From December 19th 2012 to January 21st 2013, study nurses offered 3 choices of influenza vaccine through the mobile influenza vaccination cart: self-administered ID, nurse-administered ID, or nurse-administered IM. A trained study nurse demonstrated and verbally instructed the healthcare worker using a dummy injection device. Successful self-administration was defined as safely administering the full dose of ID vaccine on the first attempt. All ID vaccine recipients were asked to complete questionnaires. Statistical analyses Descriptive statistical methods were used to calculate vaccination coverage rates and paired t tests were used to compare recalled and actual pain of injection using SAS (SAS Institute, Cary, NC).
Disclosure of Potential Conflicts of Interest
McGeer AJ received a grant received for investigator-initiated study from Sanofi Pasteur. Funding
Sanofi Pasteur provided funding for this investigator-initiated trial and approved the protocol. The study protocol was written by the investigators who were solely responsible for the conduct of the trial, collection and analysis of data, interpretation of results, and preparation of the manuscript.
2012; 12:36-44; PMID:22032844; http://dx.doi.org/ 10.1016/S1473-3099(11)70295-X 3. Weinstock DM, Eagan J, Malak SA, Rogers M, Wallace H, Kiehn TE, Sepkowitz KA. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol 2000; 21:730-2; PMID:11089659; http://dx.doi.org/10.1086/501726
Human Vaccines & Immunotherapeutics
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Volume 11 Issue 12
