Human Vaccines & Immunotherapeutics

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Annual influenza vaccination David A Kelly, David J Macey & Donna B Mak To cite this article: David A Kelly, David J Macey & Donna B Mak (2014) Annual influenza vaccination, Human Vaccines & Immunotherapeutics, 10:7, 1930-1934, DOI: 10.4161/hv.29071 To link to this article:

Published online: 08 May 2014.

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Research Paper Research Paper

Human Vaccines & Immunotherapeutics 10:7, 1930–1934; July 2014; © 2014 Landes Bioscience

Annual influenza vaccination

Uptake, barriers, and enablers among student health care providers at the University of Notre Dame Australia, Fremantle

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1 School of Medicine; University of Notre Dame Australia; Fremantle and Intern; Royal Perth Hospital; Perth, WA Australia; 2School of Medicine; University of Notre Dame Australia; Fremantle and Academic Chair in Medicine; Murdoch University; Murdoch, WA Australia; 3School of Medicine; University of Notre Dame Australia; Fremantle and Public Health Physician; Communicable Disease Control Directorate, WA Department of Health; Perth, WA Australia

Keywords: influenza, vaccination, student, health care provider Abbreviations: HCP, health care provider; UNDAF, University of Notre Dame Australia Fremantle

Despite national and international recommendations, annual influenza vaccination uptake among health care providers (HCPs) remains sub-optimal. This study investigated the uptake, enablers, and barriers to annual influenza vaccination in medicine, nursing, and physiotherapy students at the University of Notre Dame Australia, Fremantle, using an online survey and semi-structured interviews. In 2013, uptake rate of influenza vaccination was 36.3% (95% CI = 31.8–40.8%). Employment as a HCP (OR 1.6, 95% CI 1.1–2.5), being a medical student (OR 2.5, 95% CI 1.2–5.1) and eligibility for government-funded vaccine (OR 7.1, 95% CI 2.7–18.6) were independently associated with increased uptake. Awareness, cost, and convenience were identified as key barriers to vaccination with interview data suggesting that raising awareness of the benefits of influenza vaccination, along with improving student HCPs’ access to affordable, convenient vaccination are likely to improve uptake. Responsibility to increase uptake should be shared between universities and student HCPs.

Introduction Influenza remains a significant burden to the Australian health care system.1,2 Vaccination remains the most effective method of reducing infection and is endorsed by the World Health Organization3 and Australian government for certain populations, including health care providers (HCP), because of their potential to transmit influenza to persons at increased risk of complications from influenza infection.4 Influenza vaccination is effective in healthy individuals, however its efficacy might be low in vulnerable populations such as the elderly, those with comorbid respiratory conditions and the immunocompromised.5,6 This highlights the importance of achieving high vaccination rates among healthy individuals, for example HCPs, to reduce the transmission.7-10 Despite the importance, literature consistently illustrates sub-optimal vaccination rates of less than 80% among HCPs in Australia (17–58%) and other developed countries.8,11-13 The Australian government subsidizes influenza vaccination for certain at risk populations. However, HCP influenza vaccination is considered the responsibility of employers11,13,14 for the

protection of vulnerable patients and the occupational health and safety of employees. Similarly, universities have a responsibility to ensure their student HCPs are vaccinated.15 Despite this, the University of Notre Dame Australia, Fremantle (UNDAF) has no specific program designed to ensure that student HCPs undertake annual influenza vaccination. Furthermore, there is no on-campus health service where students can access vaccination. To date, there is no published information on the uptake, barriers, and enablers to influenza vaccination among Australian student HCPs. This study aims to define the uptake and investigate the enablers and barriers to influenza vaccination among the student HCPs with the ultimate goal being to improve their rates of influenza vaccination uptake.

Results Online survey An amount of 438 students (30.4%) participated in the online survey; medicine (n = 183, 41.8%) nursing (n = 187, 42.7%), and physiotherapy (n = 68, 14.5%). Ten students reported a medical

*Correspondence to: David A Kelly; Email: [email protected] Submitted: 02/04/2014; Revised: 04/20/2014; Accepted: 04/30/2014; Published Online: 05/08/2014 1930

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David A Kelly1,*, David J Macey2, and Donna B Mak3

Table 1. Demographic characteristics of the student HCP population, survey respondents, and weighted univariate chi-square results for control variables, with the likelihood of having the influenza vaccination as the dependent variable Population n = 1439

Response n = 432*

Response rate (%)


Vaccination rate (%)





























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Year of study+


1st year





2nd year





3rd year





4th year











Employed as a health care provider (HCP)





Not employed


P value uptake rate

Eligible for government-funded vaccine+^












*True respondent sample size was 428. Sample size after applying proportional weights was 432 due to rounding. +Not all responders registered complete information about school, year of study, HCP status, or eligibility for government-funded vaccine and Response rate for year of study was not available due to the university privacy policy on releasing specific data on students. #HCP refers to those students who were employed a health care provider outside of their studies. ^Eligibility for government-funded vaccine refers to students who are eligible for Australian Government-funded influenza vaccine as defined in the Australian Immunisation Handbook.4. Table 1 advises on the total number of students, number survey respondents, and number of students vaccinated against influenza categorized by age, gender, school, year of study, employment as a HCP, and eligibility for government-funded vaccination.

contraindication to influenza vaccination and were excluded from any further analyses (n = 428). Key demographic data are summarized in Table 1. The overall vaccination rate in 2013 was 36.3% (95% CI = 31.8–40.8%). Univariate analysis showed significant differences in uptake between schools (chi-square = 11.898, df = 2, P = 0.003) with higher uptake in medical (47.5%) vs. nursing (34.7%) and physiotherapy (25.3%) students. Students aged over 24 y and those eligible for government-funded vaccination also had higher uptake (Table 1). Multivariate logistic regression showed that being a medical student (OR 2.508, 95% CI 1.241–5.069), employment as a HCP (OR 1.618, 95% CI 1.052–2.491), and eligibility for government-funded vaccine (OR 7.130, 95% CI 2.733–18.604) were positively and independently associated with influenza vaccination (Table 2). Among medical students, the vaccination rate of health services based medical students in years 3 and 4 was 60.5% and 57.6% respectively compared with of campus based medical students years 1 and 2 35.0% and 35.6% respectively (P = 0.018). Being in years 3 or 4 (OR 2.853, 95% CI 1.454–5.597) and

employment as a HCP (OR 3.287, 95% CI 1.677–6.441) were positively and independently associated with influenza vaccination (Table 3). Key informant interviews Student interview data identified that all students (22 of 22) were unaware of both the Australian government’s recommendation regarding influenza vaccination of HCPs, including student HCPs, and the university’s influenza vaccination policy. None of the students interviewed were opposed to the recommendation or the policy and no students expressed an objection to being vaccinated. All students identified the benefits of vaccination for their own health, but less than half (9 of 22) were aware of the importance of HCP vaccination in protecting patients who are immunocompromised or have medical contraindications to vaccination. All students acknowledged that the ultimate responsibility for vaccination rests with the student. Affordability (15 of 22) and convenience (20 of 22) were identified by students as key positive influences on vaccination uptake. Most interviewees who had been vaccinated received the vaccination for free while on placement at a health service (7 of 11). Most students who were not vaccinated listed that a lack of convenient access (7 of

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Table 2. Multivariate logistic regression results for control variables, with the likelihood of having the influenza vaccination as the dependent variable, n = 428 Variable


95% CI

P value

Age >24 y





Employment as health care provider





Female gender





Eligible for government-funded vaccine





Medical student





Nursing student






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Advises on the independent likelihood that any student enrolled in the study is vaccinated against influenza based on age, employment as a health care provider, gender, eligibility for government-funded vaccine, and school.

11) and having to pay (6 of 11) as key barriers to vaccination. Students’ suggestions for improving vaccination uptake included reminders and the provision of the vaccine at a convenient venue, time, and/or at little or no cost. The UNDAF has no program to promote, incentivize, or subsidize influenza vaccination for its student HCPs. The staff representative of each of the 3 schools expected uptake to be low, but none were aware of any previous attempts to quantify or rectify this.

Discussion This study confirms that student HCPs’ uptake of the annual influenza vaccination is poor (36.3%) and that understanding the recommendation of influenza vaccination, cost and convenience are the key barriers faced by student HCPs. The majority of vaccinated students acknowledged that receiving the vaccine for free, while on placement, was a key enabler. The increased uptake among predominately hospital based medical students and students employed as HCPs supports this. These findings show similarities in the uptake rate between student and employed HCPs both in Australia and internationally.11,12 Convenience and awareness of influenza vaccination policies have been described as key enablers for HCPs.12,16 One key difference between HCPs and student HCPs is their access to affordable vaccination. Employers of HCPs are responsible for providing free vaccination to their employees but universities are not responsible for providing free vaccination for their student HCPs. Effectiveness, perceived risk, fear of adverse side effects or dislike of needles have been previously identified as barriers for

HCP vaccination13,17 yet none of the student HCPs interviewed expressed an objection to the influenza vaccine or shared these concerns as a barrier to vaccination. Limitations of this study include the use of self-reported vaccination status and a 30% response rate. It was not feasible, in this study, to validate vaccination status because of resource constraints and perceived unacceptability of researchers contacting individual student’s health care providers. Students who received the vaccine may be more likely to respond18 and the use of selfreported vaccination status is likely to overestimate the uptake due to the modest positive predictive values (54–81%) and high negative predictive values (85–99%) of self-reporting influenza vaccination status.19 Both limitations are likely to have resulted in over-estimation of student HCP influenza vaccine uptake, which further strengthens the need for improvement. Although this research is from one university, educational institutions should consider the implications of sub-optimal influenza vaccination rates among their student HCPs and their responsibility to improve these rates. While influenza vaccination remains a recommendation and is not mandatory, universities should be actively promoting vaccination of student HCPs to protect the health of their students, foster professional responsibility and establish sound occupational health behaviors early in their career. To improve the vaccination rates among student HCPs, UNDAF could consider promoting its vaccination policy, informing student HCPs of the benefits of vaccination, establishing an on-campus vaccination service and subsidizing vaccinations for HCP students. Future research should further examine of the enablers and barriers to influenza vaccination among student HCPs,

Table 3. Multivariate logistic regression results for control variables, with the likelihood of having the influenza vaccination as the dependent variable, medical students only, n = 183 Variable


Age >24 y



95% CI 2.196

P value 0.950

Employment as health care provider





Male gender





3rd or 4th year of study





Eligible for government-funded vaccine





Advises on the independent likelihood that a medical student is vaccinated against influenza based on age, employment as a health care provider, gender, year of study, and eligibility for government-funded vaccine.


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Physiotherapy student

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Methods All students over the age of 18 y and enrolled in a bachelor degree at the UNDAF; School of Medicine (n = 404), Nursing (n = 742), or Physiotherapy (n = 293) were invited, via email, to participate in this study. The study involved an anonymous online survey of selfreported influenza vaccination uptake and demographic variables (Table 1). Each student received an email invitation with a direct web link to the survey conducted through SurveyMonkey ®. Year of study was obtained as medical students are predominately campus based during years 1 and 2 (during which they have infrequent contact with patients approximately 50 h/year) and predominately health service based during the years 3 and 4 when they have daily clinical contact with patients. This distinction is not so clear within the schools of physiotherapy and nursing where students undertake health service placements and campus based studies in each year. Eligibility for federal government-funded vaccines and the contraindications to influenza vaccine were defined in the survey according to the Australian Immunisation Handbook.4 Data were analyzed with SPSS™ version 20 using chi-square for univariate analysis and logistic regression models for multivariate analysis. Proportional weights were applied (Medicine 0.67, Nursing 1.20, Physiotherapy 1.4) to standardise the data to the university’s distribution of student HCPs by school. The online survey was conducted in June 2013, References 1. Newall AT, Viboud C, Wood JG. Influenzaattributable mortality in Australians aged more than 50 years: a comparison of different modelling approaches. Epidemiol Infect 2010; 138:83642; PMID:19941685; S095026880999118X 2. Newall AT, Scuffham PA. Influenza-related disease: the cost to the Australian healthcare system. Vaccine 2008; 26:6818-23; PMID:18940222; http://dx.doi. org/10.1016/j.vaccine.2008.09.086 3. Influenza (seasonal). Fact Sheet no 211. World Health Organization, 2009. 4. National Health and Medical Research Group. The Australian Immunisation Handbook. 10 ed. Canberra: Department of Health and Aging; 2013. 5. Vu T, Farish S, Jenkins M, Kelly H. A meta-analysis of effectiveness of influenza vaccine in persons aged 65 years and over living in the community. Vaccine 2002; 20:1831-6; PMID:11906772; http://dx.doi. org/10.1016/S0264-410X(02)00041-5

3 mo after the commencement of that year’s influenza vaccination program. The survey was open for 6 wk and non-responders were followed up with 3 repeat invitations during this time. Qualitative data on the enablers and barriers were gathered through semi-structured interviews with 2 students (1 vaccinated, 1 not vaccinated) from each year group, of each school to a total of 22 students. These were selected at random from survey respondents who had volunteered to be interviewed. One staff member, from each school, responsible for developing their school’s immunization policy, as nominated by their Dean, was interviewed to a total of 3 staff members. All interviews involved pre-prepared, open ended questions addressing (1) knowledge and opinions of the university’s and state health department’s policy on annual HCP influenza vaccination (2) perceived enablers and barriers to influenza vaccination (3) responsibilities of the university, student associations and individual HCP students to ensure vaccination, and (4) strategies the university, student associations, and students themselves could employ to increase the uptake. Interviews were recorded and transcribed before being analyzed for themes. Ethical approval for this research was obtained from the University of Notre Dame’s Human Research Ethics Committee. Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed. Acknowledgments

We thank Professor Max K Bulsara, Chair in Biostatistics; Institute of Health Research, University of Notre Dame Australia, Fremantle Campus for his statistical advice. Ethics Approval

This project has been granted approval from The University of Notre Dame Australia Human Research Ethics Committee. (Ref # 013064F). Free and informed consent was gained from all subjects who participated. Funding Source

There was no external funding source.

6. Michiels B, Govaerts F, Remmen R, Vermeire E, Coenen S. A systematic review of the evidence on the effectiveness and risks of inactivated influenza vaccines in different target groups. Vaccine 2011; 29:9159-70; PMID:21840359; http://dx.doi. org/10.1016/j.vaccine.2011.08.008 7. Glezen WP. Herd protection against influenza. J Clin Virol 2006; 37:237-43; PMID:17008123; http:// 8. Maltezou HC, Tsakris A. Vaccination of healthcare workers against influenza: our obligation to protect patients. Influenza Other Respir Viruses 2011; 5:382-8; PMID:21668685; http://dx.doi. org/10.1111/j.1750-2659.2011.00240.x 9. Lang PO, Samaras D, Samaras N, Govind S, Aspinall R. Influenza vaccination in the face of immune exhaustion: is herd immunity effective for protecting the elderly? Influenza Res Treat 2011; 2011:419216; PMID:23074656; http://dx.doi. org/10.1155/2011/419216

10. Plans-Rubió P. The vaccination coverage required to establish herd immunity against influenza viruses. Prev Med 2012; 55:72-7; PMID:22414740; http:// 11. Seale H, Macintyre CR. Seasonal influenza vaccination in Australian hospital health care workers: a review. Med J Aust 2011; 195:336-8; PMID:21929498; mja11.10067 12. Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza vaccination of healthcare workers: a literature review of attitudes and beliefs. Infection 2006; 34:142-7; PMID:16804657; http://dx.doi. org/10.1007/s15010-006-5109-5 13. Stuart MJ. Review of strategies to enhance the uptake of seasonal influenza vaccination by Australian healthcare workers. Commun Dis Intell Q Rep 2012; 36:E268-76; PMID:23186238

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incorporating a larger sample and/or inclusion of multiple universities. The effectiveness of interventions aimed at increasing the student HCPs’ vaccination rates should also be examined. Overall, this study is the first to have quantified the rate of vaccination among Australian student HCPs and despite its modest sample suggests an appreciable risk that universities and health services must consider. This study provides a basic understanding into the enablers and barriers that universities can begin to utilize in order to improve vaccination uptake but also allows for more directed and in-depth analysis in the future having identified the key themes.

17. Hollmeyer HG, Hayden F, Poland G, Buchholz U. Influenza vaccination of health care workers in hospitals--a review of studies on attitudes and predictors. Vaccine 2009; 27:3935-44; PMID:19467744; http:// 18. Kennedy E, Santibanez T, Bridges C, Singleton J. Flu Vaccination Coverage, National Flu Survey, March 2012. Centers for Disease Control and Prevention, USA Government, 2012.

19. Zimmerman RK, Raymund M, Janosky JE, Nowalk MP, Fine MJ. Sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata. Vaccine 2003; 21:148691; PMID:12615445; S0264-410X(02)00700-4

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14. Ballestas T, McEvoy SP, Doyle J; SMAHS Healthcare Worker Influenza Vaccination Working Party. Co-ordinated approach to healthcare worker influenza vaccination in an area health service. J Hosp Infect 2009; 73:203-9; PMID:19783073; http:// 15. Operational DHCWIP. Communicable Disease Control Directorate WA Department of Health, 2012. Available from: circularsnew/pdfs/12891.pdf 16. Kaufman J, Davis J, Krause V. Influenza immunisation of doctors at an Australian tertiary hospital: immunisation rate and factors contributing to uptake. Commun Dis Intell Q Rep 2008; 32:443-8; PMID:19374273


Human Vaccines & Immunotherapeutics

Volume 10 Issue 7

Annual influenza vaccination.

Despite national and international recommendations, annual influenza vaccination uptake among health care providers (HCPs) remains sub-optimal. This s...
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