At the Intersection of Health, Health Care and Policy Cite this article as: Harunor Rashid, Jiehui Kevin Yin, Kirsten Ward, Catherine King, Holly Seale and Robert Booy Assessing Interventions To Improve Influenza Vaccine Uptake Among Health Care Workers Health Affairs, 35, no.2 (2016):284-292 doi: 10.1377/hlthaff.2015.1087

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Strengthening Immunization Programs By Harunor Rashid, Jiehui Kevin Yin, Kirsten Ward, Catherine King, Holly Seale, and Robert Booy 10.1377/hlthaff.2015.1087 HEALTH AFFAIRS 35, NO. 2 (2016): 284–292 ©2016 Project HOPE— The People-to-People Health Foundation, Inc.

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Harunor Rashid ([email protected] .gov.au) is an epidemiologist in the National Centre for Immunisation Resarch and Surveillance of Vaccine Preventable Diseases (NCIRS), Kids Research Institute, Children’s Hospital at Westmead, New South Wales, Australia. Jiehui Kevin Yin is a conjoint lecturer at the Sydney School of Public Health, Faculty of Medicine, University of Sydney, in New South Wales. Kirsten Ward is a monitoring and evaluation officer at the NCIRS, Kids Research Institute, Children’s Hospital at Westmead. Catherine King is a medical librarian at the NCIRS, Kids Research Institute, Children’s Hospital at Westmead. Holly Seale is a senior lecturer in the School of Public Health and Community Medicine, University of New South Wales, in Sydney. Robert Booy is head of clinical research at the NCIRS, Kids Research Institute, Children’s Hospital at Westmead.

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Assessing Interventions To Improve Influenza Vaccine Uptake Among Health Care Workers Despite official recommendations for health care workers to receive the influenza vaccine, uptake remains low. This systematic review of randomized controlled trials was conducted to understand the evidence about interventions to improve influenza vaccine uptake among health care workers. We identified twelve randomized controlled trials that, collectively, assessed six major categories of interventions involving 193,924 health care workers in high-income countries. The categories were educational materials and training sessions, improved access to the vaccine, rewards following vaccination, organized efforts to raise vaccine awareness, reminders to get vaccinated, and the use of lead advocates for vaccination. Only one of the four studies that evaluated the effect of a single intervention in isolation demonstrated a significantly higher vaccine uptake rate in the intervention group, compared to controls. However, five of the eight studies that evaluated a combination of strategies showed significantly higher vaccine uptake. Despite the low quality of the studies identified, the data suggest that combined interventions can moderately increase vaccine uptake among health care workers. Further methodologically appropriate trials of combined interventions tailored to individual health care settings and incorporating less-studied strategies would enhance the evidence about interventions to improve immunization uptake among health care workers. ABSTRACT

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ajor international public health authorities, such as the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC), and many countries with National Immunization Technical Advisory Groups recommend influenza vaccination for health care workers.1–3 Vaccination of health care workers has been associated with substantial reductions in the rate of influenza-like illness and allcause mortality among both staff members and patients in various health care settings.4 It has also been shown to reduce work absenteeism and

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physician visits among health care workers when the vaccine and circulating viruses match well,5,6 and economic analyses suggest that it is costsaving.6,7 Health care workers who are vaccinated also positively influence vaccine uptake among their clients, compared with workers who are not vaccinated.8 Despite the recommendations and observed benefits, the uptake of influenza vaccination among health care workers remains low in many countries. For example, seasonal influenza vaccine uptake among health care workers seldom exceeds 40 percent in Europe or 60 percent in Australia.9–13 In Spain vaccine uptake has halved

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among health care workers in just two years and has declined in a linear fashion over a period of three years.10,11 Similarly, national vaccination uptake (or “coverage”) in the United States has not improved substantially in recent years, although it has increased slightly among certain categories of health care workers.14 Several reviews of both observational studies and trials that evaluated the effectiveness of one or more interventions to improve the uptake of influenza vaccination among health care workers have illustrated that campaigns with a greater number of components were associated with higher likelihood of vaccine uptake.15–17 There is also evidence that the quality of the research or evaluation design and implementation may influence the capacity of the intervention to produce the desired result.17 No systematic review has assessed existing evidence from randomized controlled trials of interventions to improve influenza vaccination coverage among health care workers. To address this gap, we conducted a systematic review of such trials that assessed the effectiveness of interventions in increasing influenza vaccine uptake among health care workers.

Study Data And Methods Literature Search And Selection Criteria Database searches were conducted by one of the authors (King, a senior medical librarian). No date limits were applied. The last search was completed on May 29, 2015. The searches were undertaken in the following databases: Ovid MEDLINE (from 1946 to the third week in April 2015); Ovid EMBASE (from 1980 to the eighteenth week of 2015); the Cochrane Library databases, including (from inception until the issue shown) the Cochrane Database of Systematic Reviews (fourth issue of April 2015), the Database of Abstracts of Reviews of Effects (second issue of April 2015), the Cochrane Central Register of Controlled Trials (fourth issue of April 2015), the NHS Economic Evaluation Database (second issue of April 2015), and the Health Technology Assessment Database (second issue of April 2015); SCOPUS (1823–May 2015); the Web of Science Databases, including Science Citation Index Expanded (1900–May 2015), Social Sciences Citation Index (1956–May 2015), Arts and Humanities Citation Index (1975–May 2015), Conference Proceedings Citation Index—Science (1990–May 2015), and Conference Proceedings Citation Index—Social Science and Humanities (1990–May 2015); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982–May 2015); and PsycINFO (from 1806 to the third week of

May 2015). A combination of database-specific controlled vocabulary (where available) and general freetext terms was used to ensure maximal retrieval. Influenza vaccination and vaccine terms were combined with health care worker terms and limited to randomized controlled trials, using database-specific limits (where available). Details about the strategy, including the full terms used in OVID Medline, are available in the online Appendix, Section 1.18 The bibliographies of all relevant articles, including reviews, were checked to identify additional studies. Relevant websites were also explored, including those of the WHO, the CDC, Public Health England, the European Centre for Disease Prevention and Control, and the Australian Government Department of Health. Hand searching and website searches continued until June 30, 2015. Results from all of the searches were combined, and duplicate items were removed. Three of the authors (Yin, Ward, and Rashid) independently reviewed the search results. Inclusion Criteria The inclusion criteria were structured according to the participants, intervention, comparator, and outcome (PICO) model.19 Participants were any personnel in paid employment, volunteering, or learning in the following settings: acute, ambulatory, chronic, or primary care; retail pharmacy; and diagnostic laboratory. Any intervention that was tested to improve the uptake of the influenza vaccine was considered for inclusion. The comparator could be one or more other interventions or no intervention at all. Health care workers who did not receive the tested intervention were considered controls. The outcomes that were measured were the number and proportion of health care workers who were vaccinated against influenza. The only study design included in this review was the randomized controlled trial.We included only studies published in English. Data Extraction And Assessment Of Quality Of Evidence Four of the authors (Rashid, Yin, Ward, and Seale) independently extracted the data from each study. Any disagreement among the four authors was resolved by discussion with or arbitration by a fifth author (King). The data extracted included the study period, country or city where the study was conducted, sample size, type of health care workers, type of health care settings, ongoing campaign activities, baseline vaccination coverage rate, interventions used, control subjects and whether they received any intervention, end-point vaccination coverage in the study arms, and strengths and limitations of the study. Two of the authors (Rashid and Yin) indepenF eb ru a ry 2 0 16

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Strengthening Immunization Programs dently conducted a validity assessment of the included studies. The risk of bias was assessed by using a tool described in the Cochrane Handbook for Systematic Reviews.20 The tool assesses at least the following six key aspects of trial methodology: random sequence generation; allocation concealment; blinding of participants; blinding of outcome; incomplete outcome; and selective reporting to identify selection, performance, detection, attrition, reporting, and other bias. Data Synthesis Deductive thematic analysis was used to identify types of interventions in included studies. Two authors (Rashid and Yin) independently extracted the major type or types of interventions from each study and then met to discuss and agree on themes across these intervention types. Through this process, six major types of interventions were identified (Exhibit 1). The data abstracted from the studies were stratified by intervention type. Because of lack of homogeneity across the studies, only narrative synthesis was conducted. Heterogeneity was estimated using RevMan 521 and measured with the I 2 statistic. Heterogeneity was considered mild if I 2 was less than 30 percent, moderate if it was 30–50 percent, and notable if it was more than 50 percent.22,23 Limitations This study had several limitations. First, there was diversity across the studies in terms of participants (who belonged to all classes of health care workers), irrespective of whether they had direct contact with patients; intervention type; existing intervention programs; background vaccination rates among intervention and control groups; and health care settings in which the randomized controlled trials were conducted. Thus, meta-analysis was not

possible for these data. Second, as noted above, we limited the sample to English-only articles. Although this may be viewed as a potential methodological bias, it did not influence the results, as we did not come across any randomized controlled trial published in a language other than English that met our other inclusion criteria. Third, there was some minor overlap in the categories and strategies that we used. However, this was largely unavoidable and was accounted for through a detailed definition of each category (Exhibit 1). Although all included studies were randomized controlled trials, random sequence generation was not reported in seven studies.24–30 Another study did report the generation but did not show the effect of randomization because the baseline vaccination rate was significantly higher in the intervention arm than in the control arm (42 percent versus 24 percent; p < 0:001).31

Study Results Of the 2,574 titles and abstracts screened, twelve randomized controlled trials that met the inclusion criteria of the PICO model19 were included in the study (Appendix, Section 2).18 The twelve studies were conducted between 1990 and 2012 in a high-income country (Exhibit 2). Three were conducted in the United States,24,25,31 three in Canada,26,32,33 two in France,27,28 two in the Netherlands,34,35 one in the United Kingdom,29 and one in Israel.30 Five studies were carried out in acute care hospitals;24,26,31,33 another four in nursing homes;25,27,28,35 one in a mixed health care setting that included nursing homes, care facilities for the elderly, community hospitals,

Exhibit 1 Intervention Categories And Examples Of Interventions For Influenza Vaccine Uptake Among Health Care Workers Category

Type of intervention

Educational materials and training sessions

Dissemination of information (oral and written) to increase awareness and knowledge of the importance of influenza vaccination, including posters, mass mailings, fliers, newsletters, meetings, lectures, presentations, visits by experts or researchers, and videos.

Making vaccines easy to access

Includes offering free vaccine, flexible vaccination hours, or mobile vaccination cart and organizing clinics at worksites.

Lead advocates

Nominating staff who are pro-vaccination to promote or advocate vaccination, serving as a role model for other staff.

Rewards Reminder messages

Includes gifts, cupcakes, raffle tickets, coupons, coat pins, T-shirts, buttons, bracelets, and recognition for personal and work-group vaccination. Includes letters, personalized e-mail, and verbal reminders.

Organized efforts to raise awareness or promotion

Includes vaccine day or vaccine fair, which may contain components of other interventions such as presentations, fliers, and free vaccination.

SOURCE Authors’ analysis of data from Notes 15–17 and 24–35 in text.

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Exhibit 2 Summary Of Interventions Used With Changes In Influenza Vaccine Uptake Among Health Care Workers, 1990–2012 Author (note in text)

Setting

Country (study period)

Existing activities

Baseline coverage rate

Interventions

Vaccine uptake with intervention vs. control (significance)

Ohrt and McKinney (31)

University hospital

US (1990– 91)

Educational memorandum

Intervention arm: 42%; control arm: 24%

Education, reminders, and improving access

57% vs 49% (not significant)

Dey et al. (29)

Primary care and nursing homes

UK (1999)

Free vaccine, letter from expert, and posters

Not recorded

Education

Primary care: 21.9% vs. 21% (p ¼ 0:91); nursing homes:10.2% vs. 5.6% (p ¼ 0:34)

Kimura et al. (25)

Long-term care facilities

US (2002– 03)

Written policy requiring staff to receive flu vaccine

29–39%

Education, promotion, or both

Both education and promotion: 53% vs. 27% (APR: 1.45; 95% CI: 1.24, 1.71); promotion alone: 46% (APR: 1.41; 95% CI ¼ 1:17, 1.71); education alone: 34% (APR: 1.18; 95% CI: 0.93, 1.50)

Doratotaj et al. (24)

Tertiary care hospital

US (2005)

Posters, newsletters, gifts, departmental meetings, improving access

38.2% in the study year

Rewards, education, or both

42% vs. 38% (p ¼ 0:66)

Slaunwhite et al. (26)

Public hospital

Canada (2005)

Nothing mentioned

38–42%

Lead advocates

52% vs 41% (p < 0:03)

Rothan-Tondeur et al. (27) Looijmansvan den Akker et al. (35)

Geriatric health care settings

France (2005–06)

Nothing mentioned

27% (33% in second year)

Education

34% vs. 32% (p > 0:05)

Nursing homes

Netherlands (2006)

Recommendation by national bodies

About 20%

Education and lead advocates

25% vs. 16% (p ¼ 0:02)

Rothan-Tondeur et al. (28)

Geriatric health care settings

France (2005–06 and 2006–07)

Nothing mentioned

Intervention arm: 31%; control arm: 21%

Education, lead advocates, and rewards

44% vs. 27% (p < 0:001)

Abramson et al. (30)

Primary health care clinics

Israel (2007– 08)

Free vaccine, organization’s recommendation

Intervention arm: 27%; control arm: 19.9%

Education, reminders, and lead advocates

52.8% vs. 26.5% (p < 0:001)

Conner et al. (33)

Public hospitals

Canada (2008)

Vaccination campaigns

Not recorded

Education

42.2% vs. 36.3% (p ¼ 0:04)

RiphagenDalhuisen et al. (34)

University medical centers

Netherlands (2009–11)

Vaccination to selected staff, or not to vaccinate at all

Up to 37%

First year: 32.3% vs. 20.4% (p < 0:05); second year: 28.6% vs. 17.8% (p < 0:05)

Chambers et al. (32)

Mixed health care setting

Canada (2010–11 and 2011–12)

Free vaccine

Intervention arm: 43%; control arm: 62%

Education, lead advocates, rewards, improving access, and reminders Indirect education

First year: 44% vs. 57% (p ¼ 0:90); second year: 51% vs. 55% (p ¼ 0:66)

SOURCE Authors’ analysis of data from Notes 24–35 in text. NOTES Interventions are presented in chronological order. “Education” is the category “educational materials and training sessions” in Exhibit 1; “reminders” is the category “reminder messages”; “improving access” is the category “making vaccines easy to access”; “promotion” is the category “organized efforts to raise awareness or promotion.” APR is adjusted prevalence rate. CI is confidence interval.

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Strengthening Immunization Programs and academic teaching hospitals;32 one in a primary care setting;30 and one in both primary care and nursing home settings.29 Collectively, the studies present data on 193,924 health care workers. The workers were mainly medical and nursing staff members, but a few of the studies included ancillary staff members,25,27,28,30 students,31 rehabilitation therapists,25 technical staff members,33 or pharmacists.30 All of the studies assessed strategies for improving the uptake of trivalent seasonal influenza vaccine. One study also examined the effect of interventions designed to increase uptake of monovalent vaccine against the pandemic (H1N1) 2009 virus.34 The baseline vaccination uptake was recorded in ten of the studies. It ranged from 20 percent to 62 percent.24–28,30–32,34,35 Two studies27,28 were in a sense two different stages of one study conducted over two years. In the first year there was only an educational intervention, and no significant difference in vaccine uptake between the study arms was found.27 However, in the second year, when the researchers added other interventions (lead advocates and rewards), there was a significant increase in vaccine uptake in the intervention arm.28 Types Of Interventions Among the six categories of interventions identified (Exhibit 1), the most commonly used were educational materials and training sessions, or “education” (in eleven of the twelve studies, or 92 percent) (Exhibit 2). The other categories were used in fewer studies, as follows: lead advocates, five studies (42 percent); rewards and reminder messages, three studies each (25 percent); making vaccines easy to access, two studies (17 percent); and organized efforts to raise awareness or promotion, one study (8 percent). Most of the studies evaluated the role of a combination of measures. Only four studies assessed the role of an isolated intervention: education in three cases27,29,33 and lead advocates in one.26 All but one study26 used education alone or in combination with other interventions. Another study evaluated the role of indirect education provided through a “guidebook” designed for program managers of health care organizations to improve influenza vaccine coverage among their staff.32 The overall quality of the studies was modest (Exhibit 3). Only one study blinded participants,34 and only one other blinded the outcome assessment.32 Random sequence generation was reported in only five studies,31–35 and allocation concealment was done in only four.24,32,33,35 Four trials had attrition bias because of incomplete reporting.25,31,32,35 Effects Of Interventions Six of the twelve 288

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studies reported a significantly higher uptake of vaccine in the intervention arm compared to the control arm, though the difference was generally modest (5.7–26.3 percent).25,28,30,33–35 In five of the remaining six studies, a higher but nonsignificant uptake in intervention groups compared to controls was observed.24,26,27,29 In the final study, nonsignificantly lower coverage in the intervention groups was noted (a difference of 13 percentage points in the first year and 4 percentage points in the second year) compared to control groups.32 Effect Of An Individual Intervention One of the three studies27,29,33 that evaluated the effect of education in isolation demonstrated a significantly higher vaccine coverage rate in the intervention group compared to the control group (42.2 percent versus 36.3 percent) over one influenza season.33 The increase in the remaining two studies that evaluated education alone was not significant.27,29 These studies were both clinically and statistically heterogeneous (I 2 = 84 percent). The study that assessed the impact of lead advocates alone also did not report a significantly higher uptake in the intervention group compared to the control group.26 Effect Of Combined Interventions ▸ TWO INTERVENTIONS : One study demonstrated that implementing education and lead advocates resulted in moderate but significantly higher vaccine uptake in the intervention group (25 percent) compared to the control group (16 percent) over one influenza season (Exhibit 2).35 A second study demonstrated that a combination of education and promotion increased vaccination coverage from 27 percent to 53 percent over one influenza season.25 This study also examined both education and promotion (a vaccine day) separately and found that promotion alone was significantly effective (with a similar adjusted prevalence ratio and 95% confidence interval as the two interventions combined: APR, 1.45; 95% CI, 1.24, 1.71, respectively), but the educational program alone was not significantly effective (APR: 1.18; 95% CI: 0.93, 1.50).25 A third study24 investigated the effect of education (a letter) and a reward (a raffle ticket using three intervention arms—the education alone, the reward alone, or both together—all of which were compared with a control group whose members received no intervention apart from the hospital’s existing programs). No significant difference in uptake between any intervention group and the control group during the course of an influenza season was observed. Overall, uptake was somewhat higher in study subjects compared with all hospital health care workers (41 percent versus 38 percent), but the

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Exhibit 3 Summary Of Risk Of Bias In The Twelve Randomized Controlled Trials Of Influenza Vaccine Uptake Among Health Care Workers

SOURCE Authors’ analysis of data from Notes 24–35 in text. NOTES The risk of bias was assessed according to a Cochrane Collaboration tool (see Note 20 in text). The summary graph was generated using RevMan 5 (see Note 21 in text). A green circle (with a plus sign) indicates low risk of bias. A red circle (with a minus sign) indicates high risk of bias. A blank cell means that the risk of bias is unclear.

difference was not significant.24 ▸ THREE INTERVENTIONS : One study28 showed that a combination of education, lead advocates, and a reward (recognition for personal and work-group vaccination) increased vaccine coverage among health care workers in French geriatric units over one influenza season. Another study31 demonstrated that a combination of education (a memorandum outlining vaccine indications), reminders (e-mail and phone calls), and improving access did not significantly increase vaccine uptake compared to a control group over one influenza season. However, the baseline vaccination rate was significantly higher in the intervention group than in the control group (42 percent versus 24 percent; p < 0:01), which suggests that there was a larger improvement in the control group.31 A third study30 examined the combined effect of education (a lecture to staff members by a family physician), reminders (e-mail with evidence-based information about the benefits of vaccination), and lead advocates (key staff members—a physician or a nurse—to promote the influenza vaccine to peers). These strategies targeted primary care staff members with direct patient contacts. Significantly higher vaccine uptake in the intervention group was observed compared to the control group over one influenza season. A highly significant (p < 0:001) independent association was also observed between

the combined interventions and health care worker vaccination, with an odds ratio of 3.51 (95% CI: 2.03, 6.09).30 ▸ FIVE INTERVENTIONS : One study34 evaluated the effect of education, lead advocates, rewards, improving access, and reminders in increasing seasonal and pandemic influenza vaccination of staff members at eight university medical centers in the Netherlands over two influenza seasons (2009–10 and 2010–11). Seasonal vaccine uptake was significantly higher in the intervention group than in the control group in both 2009 and 2010. Similarly, uptake of the pandemic vaccine in 2009 was higher in the intervention group than in the control group, and uptake of the first dose was greater than that of the second dose (dose 1: 61.7 percent versus 38 percent, p < 0:05; dose 2: 45.8 percent versus 24.4 percent, p < 0:05).34 Effect Of An Indirect Intervention The usefulness of a guidebook and supplementary educational tools was assessed in a study in several Canadian provinces over two influenza seasons (2010–11 and 2011–12).32 The step-by-step guidebook was developed by the Canadian Healthcare Influenza Immunization Network for program managers of health care organizations. Face-to-face educational workshops were conducted for the managers on how to use the guidebook and tools. No significant change in influenza vaccine uptake among health care Febr uary 201 6

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Strengthening Immunization Programs workers was observed. However, there was a significant increase in median vaccination rate in the intervention group in the second year compared to the baseline year (43 percent versus 51 percent, p < 0:01).32

Discussion This review of twelve randomized controlled trials, which assessed the effectiveness of strategies to increase influenza vaccine uptake among health care workers, illustrates some modest improvement in vaccine uptake. Strategies implemented alone (either education or lead advocates) were not as efficacious as those implemented in combination. Where baseline coverage was measured, it was generally low.24–28,30– 32,34,35 Thus, there were opportunities for improvement, although coverage did not often reach desired levels. Previous systematic reviews of both observational studies and randomized controlled trials have shown that a mandatory workplace vaccination policy can significantly increase vaccine uptake.15,16 However, mandating vaccination or imposing penalties for nonvaccination (for example, the compulsory completion of a statement declining vaccination) have not been evaluated through a randomized controlled trial, probably because use of this strategy would be impractical or ethically difficult.9,36–38 There is documented opposition to mandatory vaccination policies among health care workers.39,40 Nonetheless, up to 88 percent of health care workers at St. Jude Children’s Research Hospital, in Memphis, Tennessee, who opposed mandatory vaccination still reported receiving influenza vaccine.40 Completion of a mandatory declination form or the mandatory use of face masks by unvaccinated staff members who have direct patient contact has been shown to increase the vaccination rate to around 90 percent.41–44 Various observational studies illustrate that comprehensive targeted promotion can improve influenza vaccine uptake by health care workers. In a US teaching hospital, David Fedson found an increase in vaccine uptake (24 percent to >90 percent over a period of seven years) among medical residents, following the implementation of various promotional strategies.45 These included the active promotion of vaccination by the clinic director; assignment of a nurse with specific responsibility for vaccination; and distribution of posters, leaflets, and paycheck advice notices. Joyce Hood and Andrea Smith demonstrated that a leadership-modeled approach with the theme “follow the leader” increased workplace vaccine uptake at an integrated pediatric health care organization from a baseline of 290

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66 percent to 84 percent over a period of one year.46 An observational study by Elizabeth Cooper and Mary O’Reilly evaluated a combination of mobile carts (“needles on wheels”);47(p232) vaccination in the early morning, evening, and night; cooperation from lead advocates in various medical specialities; and a brochure about influenza vaccination in a hospital setting. This combination of interventions increased vaccine uptake among staff members from 8.3 percent in 1996 to 49 percent in 2000.47 Lisa Esolen and coauthors demonstrated that combining a requirement for unvaccinated health care workers to wear a face mask with increasing access to the vaccine achieved a rise in coverage from ≤61 percent to >90 percent among health care workers in various hospital and ambulatory care settings over a period of one year.41 Jonathan Perlin and colleagues demonstrated that across three influenza seasons, a combination of steadfast leadership support, continuous education, communication efforts, and a mandate for the unvaccinated to wear a face mask led to over 90 percent of staff members’ receiving the influenza vaccine in a private health care organization over a period of one year.43 Despite promising evidence from observational studies, some of these interventions have not been evaluated through a randomized controlled trial. The use of innovative strategies—such as electronic enrollment, a tracking process to identify and follow up with unvaccinated health care workers,42 and a patient-centered, evidencebased, leadership-modeled program46—has demonstrated effectiveness in improving vaccine uptake. These strategies should be further evaluated using practical designs that are methodologically and ethically appropriate. To appropriately tailor strategies to increase uptake of vaccination among health care workers, it is important to understand what drives them to accept or reject vaccination and change their behavior. The evidence indicates that selfprotection, instead of protection of patients, is the strongest and most consistent driver of health care workers’ decisions to accept vaccination.48 However, benefits to self, patients, or both have been cited as the most frequent reasons for accepting seasonal and pandemic influenza vaccines: One of these reasons is cited as the main rationale by up to 84 percent of people for accepting seasonal influenza vaccination and by up to 86 percent for accepting the pandemic vaccination.40,48 Two independent reviews have shown that health care workers have a wide range of misconceptions surrounding influenza, their role in

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transmitting it to patients, and the importance of vaccination.48,49 Many health care workers also report actual or perceived lack of convenient access to vaccine and fear of adverse events resulting from vaccination.49 Therefore, it is plausible that interventions to increase access could increase vaccine uptake. Only two randomized controlled trials that evaluated the effect of improved access to the vaccine31,34 were identified through our review process. However, in most of the other studies we investigated, free vaccine was standard practice, and thus the control groups also received it24,29–32,35—but that component of the intervention to increase uptake of the vaccine was not specifically evaluated. In general, few studies used comprehensive interventions to address the key concerns of health care workers. Nonetheless, results from existing observational studies illustrate that addressing at least some of those concerns led to an increase in vaccine uptake.41,43,47 The overall quality of the randomized controlled trials that we reviewed was modest. BeThis work was funded in part by the Australian National Health and Medical Research Council’s Centre of Research Excellence in Population Health Research. Robert Booy has received funding from Baxter, Seqirus,

cause of their diversity of interventions and settings and notable statistical heterogeneity, we did not consider it appropriate to perform a meta-analysis. Additionally, random sequence generation was not reported in most studies. There is evidence from a recent systematic review evaluating strategies to improve influenza vaccination among health care workers that trial quality affects the results of the evaluation.17

Conclusion This review highlights the lack of high-quality randomized controlled trials that have assessed interventions to improve the uptake of vaccination among health care workers. The available trials demonstrate only modest improvement in uptake. Where methodologically appropriate, further controlled studies are needed—particularly of the use of innovative strategies—to produce better-quality evidence of how to improve influenza vaccine uptake among health care workers. ▪

GlaxoSmithKline, Merck, Novartis, Pfizer, Roche, Romark, and Sanofi Pasteur for the conduct of sponsored research, travel to make presentations at conferences, or consultancy work; all funding received was directed to

research accounts at the Children’s Hospital at Westmead, in Westmead, Australia. Holly Seale previously received funding for investigator-led research from GlaxoSmithKline, Seqirus, and Sanofi Pasteur.

NOTES 1 World Health Organization. WHO recommendations for routine immunization— summary tables [Internet]. Geneva: WHO; 2015 Feb 27 [cited 2015 Dec 11]. Available from: http://www.who.int/ immunization/policy/ immunization_tables/en 2 Pearson ML, Bridges CB, Harper SA, Healthcare Infection Control Practices Advisory Committee (HICPAC), Advisory Committee on Immunization Practices (ACIP). Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006; 55(RR-2):1–16. 3 Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB, Advisory Committee on Immunization Practices (ACIP), et al. Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2005;54(RR-8):1–40. 4 Ahmed F, Lindley MC, Allred N, Weinbaum CM, Grohskopf L. Effect of influenza vaccination of healthcare personnel on morbidity and

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mortality among patients: systematic review and grading of evidence. Clin Infect Dis. 2014;58(1):50–7. Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA. 1999; 281(10):908–13. Bridges CB, Thompson WW, Meltzer MI, Reeve GR, Talamonti WJ, Cox NJ, et al. Effectiveness and costbenefit of influenza vaccination of healthy working adults: a randomized controlled trial. JAMA. 2000; 284(13):1655–63. Burls A, Jordan R, Barton P, Olowokure B, Wake B, Albon E, et al. Vaccinating healthcare workers against influenza to protect the vulnerable—is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine. 2006; 24(19):4212–21. Baron G, De Wals P, Milord F. Vaccination practices of Quebec family physicians. Influenza vaccination status and professional practices for influenza vaccination. Can Fam Physician. 2001;47:2261–6. Maltezou HC, Poland GA. Vaccination policies for healthcare workers

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in Europe. Vaccine. 2014;32(38): 4876–80. Jiménez-García R, Rodríguez-Rieiro C, Hernandez-Barrera V, Carrasco Garrido P, López de Andres A, Esteban-Vasallo MD, et al. Negative trends from 2008/9 to 2011/12 seasons in influenza vaccination coverages among high risk subjects and health care workers in Spain. Vaccine. 2014;32(3):350–4. Castilla J, Martínez-Baz I, Godoy P, Toledo D, Astray J, García S, et al. Trends in influenza vaccine coverage among primary healthcare workers in Spain, 2008–2011. Prev Med. 2013;57(3):206–11. Seale H, Macintyre CR. Seasonal influenza vaccination in Australian hospital health care workers: a review. Med J Aust. 2011;195(6):336– 8. Stuart MJ. Review of strategies to enhance the uptake of seasonal influenza vaccination by Australian healthcare workers. Commun Dis Intell Q Rep. 2012;36(3):E268–76. Black CL, Yue X, Ball SW, Donahue SM, Izrael D, de Perio MA, et al. Influenza vaccination coverage among health care personnel— United States, 2013–14 influenza season. MMWR Morb Mortal Wkly

Febr uary 201 6

35:2

Downloaded from content.healthaffairs.org by Health Affairs on February 17, 2016 at UNIVERSITY OF YORK

H e a lt h A f fai r s

291

Strengthening Immunization Programs Rep. 2014;63(37):805–11. 15 Lam PP, Chambers LW, MacDougall DM, McCarthy AE. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ. 2010;182(12): E542–8. 16 Hollmeyer H, Hayden F, Mounts A, Buchholz U. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses. 2013;7(4):604–21. 17 Schmidt S, Saulle R, Di Thiene D, Boccia A, La Torre G. Do the quality of the trials and the year of publication affect the efficacy of intervention to improve seasonal influenza vaccination among healthcare workers? Results of a systematic review. Hum Vaccin Immunother. 2013;9(2):349–61. 18 To access the Appendix, click on the Appendix link in the box to the right of the article online. 19 Da Costa Santos CM, de Mattos Pimenta CA, Nobre MR. The PICO strategy for the research question construction and evidence search. Rev Lat Am Enfermagem. 2007; 15(3):508–11. 20 Higgins JPT, Green S, editors. Cochrane handbook for systematic reviews of interventions: version 5.1.0 [Internet]: London: Cochrane Collaboration; [updated 2011 Mar; cited 2015 Dec 11]. Available from: http://handbook.cochrane.org/ 21 Cochrane Informatics and Knowledge Management Department. RevMan [Internet]. London: Cochrane Collaboration; [cited 2015 Dec 11]. Available from: http:// tech.cochrane.org/revman 22 Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–58. 23 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003; 327(7414):557–60. 24 Doratotaj S, Macknin ML, Worley S. A novel approach to improve influenza vaccination rates among health care professionals: a prospective randomized controlled trial. Am J Infect Control. 2008;36(4):301–3. 25 Kimura AC, Nguyen CN, Higa JI, Hurwitz EL, Vugia DJ. The effectiveness of vaccine day and educational interventions on influenza vaccine coverage among health care workers at long-term care facilities. Am J Public Health. 2007;97(4): 684–90. 26 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

292

H e a lt h A f fai r s

Febr uary 201 6

35:2

Control. 2009;24(3):159–64. 27 Rothan-Tondeur M, Filali-Zegzouti Y, Belmin J, Lejeune B, Golmard JL, de Wazières B, et al. Assessment of healthcare worker influenza vaccination program in French geriatric wards: a cluster-randomized controlled trial. Aging Clin Exp Res. 2010;22(5–6):450–5. 28 Rothan-Tondeur M, Filali-Zegzouti Y, Golmard JL, De Wazieres B, Piette F, Carrat F, et al. Randomised active programs on healthcare workers’ flu vaccination in geriatric health care settings in France: the VESTA study. J Nutr Health Aging. 2011;15(2): 126–32. 29 Dey P, Halder S, Collins S, Benons L, Woodman C. Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial. J Public Health Med 2001;23(4):346–8. 30 Abramson ZH, Avni O, Levi O, Miskin IN. Randomized trial of a program to increase staff influenza vaccination in primary care clinics. Ann Fam Med. 2010;8(4):293–8. 31 Ohrt CK, McKinney WP. Achieving compliance with influenza immunization of medical house staff and students. A randomized controlled trial. JAMA. 1992;267(10):1377–80. 32 Chambers LW, Crowe L, Lam PP, MacDougall D, McNeil S, Roth V, et al. A new approach to improving healthcare personnel influenza immunization programs: a randomized controlled trial. PLoS One. 2015; 10(3):e0118368. 33 Conner M, Godin G, Norman P, Sheeran P. Using the questionbehavior effect to promote disease prevention behaviors: two randomized controlled trials. Health Psychol. 2011;30(3):300–9. 34 Riphagen-Dalhuisen J, Burgerhof JG, Frijstein G, van der GeestBlankert AD, Danhof-Pont MB, de Jager HJ, et al. Hospital-based cluster randomised controlled trial to assess effects of a multi-faceted programme on influenza vaccine coverage among hospital healthcare workers and nosocomial influenza in the Netherlands, 2009 to 2011. Euro Surveill. 2013;18(26):20512. 35 Looijmans-van den Akker I, van Delden JJ, Verheij TJ, van der Sande MA, van Essen GA, RiphagenDalhuisen J, et al. Effects of a multifaceted program to increase influenza vaccine uptake among health care workers in nursing homes: a cluster randomised controlled trial. Vaccine. 2010;28(31):5086–92. 36 Caplan A. Time to mandate influenza vaccination in health-care workers. Lancet. 2011;378(9788):310–1. 37 Booy R, Rashid H, Yin JK, Khandaker

38

39

40

41

42

43

44

45

46

47

48

49

G, Leask J. Mandating influenza vaccination in health-care workers. Lancet. 2011;378(9803):1626. Isaacs D, Leask J. Should influenza immunisation be mandatory for healthcare workers? No. BMJ. 2008;28(337):a2140. Douville LE, Myers A, Jackson MA, Lantos JD. Health care worker knowledge, attitudes, and beliefs regarding mandatory influenza vaccination. Arch Pediatr Adolesc Med. 2010;164(1):33–7. Hakim H, Gaur AH, McCullers JA. Motivating factors for high rates of influenza vaccination among healthcare workers. Vaccine. 2011; 29(35):5963–9. Esolen LM, Kilheeney KL, Merkle RE, Bothe A. An alternate approach to improving healthcare worker influenza vaccination rates. Infect Control Hosp Epidemiol. 2011; 32(7):703–5. Palmore TN, Vandersluis JP, Morris J, Michelin A, Ruprecht LM, Schmitt JM, et al. A successful mandatory influenza vaccination campaign using an innovative electronic tracking system. Infect Control Hosp Epidemiol. 2009;30(12):1137–42. Perlin JB, Septimus EJ, Cormier SB, Moody JA, Hickok JD, Bracken RM. Developing a program to increase seasonal influenza vaccination of healthcare workers: lessons from a system of community hospitals. J Healthc Qual. 2013;35(6):5–15. Polgreen PM, Septimus EJ, Parry MF, Beekmann SE, Cavanaugh JE, Srinivasan A, et al. Relationship of influenza vaccination declination statements and influenza vaccination rates for healthcare workers in 22 US hospitals. Infect Control Hosp Epidemiol. 2008;29(7):675–7. Fedson DS. Influenza vaccination of medical residents at the University of Virginia: 1986 to 1994. Infect Control Hosp Epidemiol. 1996;17(7):431–3. Hood J, Smith A. Developing a “best practice” influenza vaccination program for health care workers—an evidence-based, leadership-modeled program. AAOHN J. 2009;57(8): 308–12. Cooper E, O’Reilly M. A novel staff vaccination strategy: Infect Control Hosp Epidemiol. 2002;23(5):232–3. Vasilevska M, Ku J, Fisman DN. Factors associated with healthcare worker acceptance of vaccination: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2014;35(6):699–-708. Hofmann F, Ferracin C, Marsh G, Dumas R. Influenza vaccination of healthcare workers: a literature review of attitudes and beliefs. Infection. 2006;34(3):142–7.

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Assessing Interventions To Improve Influenza Vaccine Uptake Among Health Care Workers.

Despite official recommendations for health care workers to receive the influenza vaccine, uptake remains low. This systematic review of randomized co...
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