Vaccine 32 (2014) 606–610
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Examining the views of key stakeholders regarding the provision of occupational influenza vaccination for healthcare workers in Australia Yi Chen Lim a , Holly Seale b,∗ a b
UNSW Medicine, University of New South Wales, New South Wales, Australia School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, New South Wales, Australia
a r t i c l e
i n f o
Article history: Received 20 August 2013 Received in revised form 6 November 2013 Accepted 15 November 2013 Available online 27 November 2013 Keywords: Healthcare workers Influenza Vaccination Hospitals
a b s t r a c t Annual vaccination of hospital healthcare workers (HCWs) may be an effective measure to reduce the transmission of healthcare associated influenza. However, vaccine coverage rates among HCWs in most public Australian hospitals are below satisfactory for a number of reasons. This study aimed to examine the opinions of key health stakeholders on current issues regarding HCW influenza vaccination. A qualitative study involving semi-structured interviews was undertaken with key Australian health stakeholders representing different organizations and sectors involved in influenza vaccination and policy. Amongst the participants, there was overwhelming support for HCW influenza vaccination. They viewed vaccination as one of the most important preventive measures for healthcare associated influenza and generally agreed that vaccination of HCWs reduces the overall risk of transmission to patients. However, there were contradictory attitudes regarding the evidence available for justifying the impact of vaccinating HCWs against influenza. Amongst the stakeholders interviewed, there was support for continuing to promote influenza vaccination for HCWs via the conventional framework. Participants recommended that hospitals continue to use conventional, voluntary strategies to increase vaccine coverage such as education and mobile carts. Given that the World Health Organization has included HCWs as a target group for influenza vaccination, Australian hospitals may need to start considering the use of mandatory policies in the near future. © 2013 Elsevier Ltd. All rights reserved.
1. Introduction As documented in the Australian immunisation handbook 10th Edition [1], all healthcare workers (HCWs), including staff and students directly involved in patient care or the handling of human tissues, are highly recommended to be vaccinated against influenza. The handbook proposes that healthcare employers should implement a comprehensive occupational vaccination program encompassing a vaccination policy, tracking of current staff vaccination records, provision of information about the relevant vaccinepreventable diseases, and the management of vaccine refusal (e.g., strategies to reduce the risk of a non-vaccinated HCW transmitting disease to vulnerable persons). Lastly, employers should take all reasonable steps to encourage non-immune workers to be vaccinated.
∗ Corresponding author at: School of Public Health & Community Medicine, Level 2, Samuels Building, Faculty of Medicine, University of New South Wales, Sydney 2052, Australia. Tel.: +61 2 9385 3129; fax: +61 2 9313 6185. E-mail addresses: [email protected] (Y.C. Lim), [email protected] (H. Seale). 0264-410X/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2013.11.063
Despite numerous attempts aimed at increasing acceptance, recorded coverage rates of seasonal influenza vaccination amongst hospital HCWs are poor and well below the 80% target recommended by the literature [2]. In a recent Australian study, the rates of HCW influenza vaccine coverage were found to be between 16.3 and 58.7% [3]. The findings from the Australian study upholds those from Europe, with documented rates ranging from 14.8 to 40.5% [4]. Whilst in the United Kingdom, despite recommendations by the Department of Health, uptake of seasonal flu vaccine was only 35% among frontline healthcare workers in 2011 [5]. Recent data from Canada, states that the vaccine coverage rates among HCWs ranges from 26 to 61% [6], while in Asia, lower levels of influenza vaccine uptake amongst HCWs have been documented in mainland China (18%) [7] and Hong Kong (30%) [8]. Lastly, while the CDC has reported that HCW influenza vaccination rates have steadily increased over the last decade in the United States [9], rates reported from different institutions remain low, with a national average of about 40% [10–12]. However, in recent years there has been a shift in coverage rates in some healthcare agencies or systems associated with the introduction of declination forms and/or mandatory vaccination policies [13], with some studies documenting increases in vaccination rates between 8.6 and 39.8% [14,15]. While rates of >90% have been
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reported in hospitals that have mandated influenza vaccination [13,16,17]. In Australia, whether to provide free influenza vaccine to HCWs is a policy decision for each hospital or jurisdiction and is therefore, not uniform across the country. To the best of our knowledge, there has not been a shift to introduce any policies or stronger recommendations in hospitals across the country. While receiving the influenza vaccine is ‘highly recommended’ for Australian hospital HCWs; it is not an occupational requirement and hence, uptake remains low. In 2010, we undertook a qualitative study to examine the hospital policies and practices regarding occupational influenza vaccination of HCWs in Australia [18]. From the interviews conducted, it was clear that the hospitals were implementing multiple strategies to educate, promote, and deliver the vaccine to staff. However, resources and support were not always available to assist with the campaigns and the reality for many of the hospitals studied was that there was limited capacity to implement the vaccination campaigns at the levels high enough to raise compliance rates. Building on from that work, we were interested to find out the views of key stakeholders responsible for setting policy and agenda around occupational vaccination towards occupational influenza vaccination. 2. Methods
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interview. In addition, the interviewer used paraphrasing and additional questions to seek clarification. This ensured that the study included most of the topics and was flexible to changes depending on the actual scenario. Questions were also asked in an open-ended manner to allow room for expansion. For example, interviews often began with a broad question like “what are your thoughts about the use of the influenza vaccine in hospitals?” to allow participants to freely discuss their opinions. Prompts were only given when the interviewer deemed they were required to encourage the conversation back to topic. During the interviews, member checking was conducted to ensure that the ideas identified during the early phase of analysis were appropriate. HS conducted all interviews either in person (n = 1) or via telephone (n = 20).
2.4. Data analysis The interviews were digitally recorded, transcribed verbatim, and analysed thematically. Two investigators jointly developed the list of themes after one quarter of the transcripts had been analysed. An agreed framework was then applied to another sub-sample of transcripts and modified further. Using this final framework, all of the transcripts were analysed and coded. Text was organized within the identified themes of the developed framework without the use of any software.
2.1. Study design 3. Results Semi-structured interviews were undertaken with key leaders representing different health organizations and sectors in Australia to explore their opinions towards the provision of occupational influenza vaccination for HCWs. The Human Research Ethics Advisory Panel (social/medical) at the University of New South Wales reviewed and approved this study. 2.2. Participants Key healthcare stakeholders in this study were defined as individuals who are officially involved with policy making or the implementation of control strategies for communicable diseases including seasonal influenza in hospital environment. This principally encompassed personnel such as infection control officers, key infectious disease opinion leaders, and health department leaders. Participants were recruited to the study via two approaches. Firstly, an online search of health department websites was conducted to identify potential candidates matching the selection description. Each candidate was then followed up via email with an invitation letter. Secondly, interested candidates were asked to directly recommend any colleagues who would be willing to participate as well. Participants were only included into the study when full written consent had been received. An effort was made to recruit at least one participant from each of Australia’s states and territories in order to capture a broad range of views on issues affecting the country. This study did not collect any identifiable personal information from the participants. 2.3. Data collection An interview guide was jointly developed and reviewed by the researchers to identify key areas of interest for the study. This included a series of questions related to the following topics: general attitudes around the use of the influenza vaccine for HCWs, knowledge regarding the available evidence on vaccination, challenges associated with the current occupational vaccine provision system, and possible barriers and strategies in improving coverage. The list of topics served only as a general direction during each
Thirty-nine stakeholders were initially invited to participate in the study. Of those, 10 were non-contactable, five declined (as they believed they were not the appropriate person to be interviewed), while three were no longer in their positions. The remaining 21 stakeholders consented to participate and were interviewed. Participants included immunization managers/directors, senior medical advisors/officers from the health department, communicable disease directors, and public health nurses responsible for coordinating hospital campaigns. All states and territories of Australia were represented. The interview results are presented below according to the themes that were identified.
3.1. Core component of hospital health and safety agenda There was overwhelming support for HCW influenza vaccination amongst the participants. Influenza vaccination of HCWs was rated as being equally as important as staff complying with handhygiene and home quarantine to help protect against healthcare associated infections. Participants unanimously agreed that occupational influenza vaccination should be a core component of every hospital’s occupational safety agenda.
3.2. Influenza vaccine’s effectiveness and credibility of evidence While the current influenza vaccine was considered to be highly effective by some participants, others shared a more reserved view and classified the vaccine’s effectiveness as “moderate” or “debatable”. Participants agreed that there is currently a lack of published evidence supporting the impact of vaccinating staff against influenza in the hospital setting. It was suggested that this lack of high level evidence makes it difficult to convince some HCWs to get vaccinated, especially those who are medically trained. On the other hand, other participants reasoned that there is no dire need to obtain additional data to justify the use of the vaccine, given that it is a common belief that influenza vaccination of healthy adults is beneficial.
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“If we had more evidence to actually see that vaccinating the staff did reduce the transmission of disease to patients I think that it might be a bit easier for us. I think the more evidence that you have the better your case is. So although there’s evidence out there, and I’ve certainly seen some presentations and read articles to suggest that it does, particularly in residential aged care facilities, I don’t think there’s enough.” (Participant 2) “. . .. I certainly don’t think that there is any evidence that it’s not effective. It’s just an absence of evidence that it is effective. I mean obviously you can be vaccinated and not necessarily stop that, it’s not 100% effective. But given that there’s a [Health department] recommendation, and the professional duty, and occupational health and safety issues that are there, even if there isn’t evidence, I mean that’s not an argument for not doing it.” (Participant 12) “I don’t think that in actual fact that there is sufficient evidence upon which to actually persuade the skeptics. I’m not saying the skeptics are those people that are anti-immunization; I think it’s the skeptics that in actual fact are specifically the medical staff who are very analytical people, so therefore when you’re actually trying to actually use evidence as a means of mechanism of influencing people, I think that sometimes the evidence is a little rubbery.” (Participant 17)
3.3. Commitment and responsibility to occupational vaccination When asked to comment on the level of commitment being made by hospitals to increase staff influenza vaccination coverage, the responses were contradictory. While there were those who suggested that there was extreme variability across sites, others believed that Australian hospitals were doing all they could to promote the vaccine. However, it was suggested that within some institutions, the support for the influenza vaccination of staff was lacking from hospital directors or ward/department managers and that in some circles it may just be seen as an extra cost. A lack of collaboration and drive amongst the occupational health staff (i.e., those responsible for delivering the programs) was also suggested. “The hospital certainly supports it, and they actively encourage it . . . in a very small way. But there certainly could be more that could be done.” (Participant 19) “No, I think most of them aren’t doing enough and most of them think that they’re saving money by not getting everybody vaccinated. I mean, you know, they have to pay for the vaccination service, and, they see that as an upfront cost but if they do their sums and worked out the cost-benefit ratio in their terms of staff sickness, they wouldn’t be thinking that way, but generally there isn’t very much management support for good immunization programs.” (Participant 4) In comparison to the prevention of other healthcare associated infections or vaccine preventable diseases, participants thought that less attention was given to the prevention of healthcare associated influenza. Participants suggested that this may be associated with the fact that there is currently no national key performance indicator for occupational influenza vaccination. It was suggested that there is a boundary around how much the government can intervene to improve coverage. Furthermore, many participants commented that the structure of the Australian healthcare system currently is moving towards decentralization where hospitals are divided into local health districts to operate autonomously. In this setting, the role and influence of state government will probably further diminish.
3.4. Traditional barriers impact on uptake Access to the vaccine was proposed as the primary system barrier to increasing coverage in hospitals. In terms of resource factors such as issues around staffing levels and/or funding of the influenza vaccine, participants did not view these issues as particularly serious. Although, some agreed that more funding would benefit the situation, they also highlighted that the vaccines are cheap and are not too difficult to provide to the HCWs. 3.5. Reliance on the traditional measures to increase vaccine uptake Participants recommended that hospitals should continue to promote the use of conventional, voluntary strategies to increase vaccine coverage. Foremost, there was universal agreement that hospital promotion campaigns should primarily revolve around educating HCWs to overcome their attitudinal barriers. The need to promote to HCWs the benefits of regular influenza vaccination and their role in influenza transmission was emphasized, along with the need to dispel any misconceptions they have related to influenza vaccines. “I think education is the key; I think we need to be looking at how the education is delivered and I think we need to be asking the healthcare workers themselves how they would like to receive the information.” (Participant 2) Aside from needing to increase the amount of education provided to staff members, participants also highlighted that it was important to focus on the accessibility and logistical aspects of delivering the influenza vaccine to HCWs. Among the different strategies proposed, mobile vaccine carts was suggested to be the most effective means of improving accessibility. It was also recommended that hospitals should set up more vaccination clinics at convenient shifts for HCWs. Away from the more traditional approaches to increasing vaccination uptake; some participants recommenced the use of incentives or friendly competitions to increase vaccine rates. Lastly, it was also suggested that some form of role modeling should be considered as well for vaccine campaigns. 4. Discussion Using qualitative methods, this study explored the opinions of key health stakeholders on current issues regarding HCW influenza vaccination. Amongst our participants, there was overwhelming support for the need to vaccinate hospital HCWs against influenza. Participants proposed that hospitals should continue to use conventional promotion and delivery strategies in order to achieve their influenza vaccine targets. Participants highlighted the need to improve the: (1) approaches used to educate HCWs and (2) the strategies used to distribute the vaccine. Very few participants suggested that there was a need for restructuring the hospital directives towards a more regulated model. The most commonly suggested mechanism for improving vaccination rates was the use of education campaigns. Participants spoke of the need to promote to HCWs the benefits of regular influenza vaccination and their role in influenza transmission, along with the need to dispel any misconceptions they have related to influenza vaccines. In general, most studies show that campaigns encompassing multiple interventions including notification, education, and provision of vaccination simultaneously yield better results than those that only employ a single intervention [19]. Of these three approaches, the use of education has been found to be the key component of a successful campaign, with increased knowledge
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regarding influenza vaccination positively correlated with higher uptake rates among HCWs [20]. As advocated by Hollmeyer et al. a successful program must include culturally sensitive education on the risk of influenza and the overall benefits of vaccination, tailored to specific professional characteristics [21]. Finding the correct interventions to include in a promotion campaign can be difficult. In a recent study by Thompson et al. twelve vaccine promotion strategies were compared to examine the potential impact on the likelihood of being vaccinated [22]. From their survey of 1670 HCWs, they found that about half (47–60%) of the unvaccinated HCWs rated 10 of 12 interventions as having “neutral” or “no effect” on the likelihood they would be vaccinated next season. For all 12 interventions at least 1 in 7 unvaccinated HCWs reacted negatively, reporting that a given intervention would make them “less likely” to be vaccinated. A vaccine requirement was listed as the number one intervention that would make them more likely to be vaccinated next season. This was followed by a severity warning from the CDC regarding the upcoming season and receiving information about how the vaccine “reduces the chance of giving the flu to patients” and receiving information about the “risks of getting influenza from patients”. The intervention ranked as least likely to influence future uptake was having an “electronic appointment link, which allows you to pick date/time” and the requirement to “be vaccinated or sign a declination form”. In conclusion, it appeared that the information based interventions (aside from policy changes) appealed the most to both unvaccinated and vaccinated HCWs. [22]. While it is important to educate HCWs about the need for the flu vaccine and to also provide easily accessible locations for vaccinations, most sources suggest that conventional programs have their limitations [17,23]. In general, coverage from voluntary influenza vaccine programs are realistically capped at around 60%, which is evidently lower than compulsory vaccination programs [24]. Previous reports have described a “ceiling effect”, a seemingly maximized influenza vaccination coverage range above which further voluntary interventions are insufficient at increasing vaccine uptake [25]. Even multi-faceted quality improvement initiatives have hit similar ceilings, finding it difficult or impossible to raise and maintain annual vaccination coverage above 75%. In some rare instances, coverage rates close to or above 80% has been reported in settings, which have utilized non-mandatory campaigns. For example, Virginia Hospital Centre (VHC) in the United States managed to achieved a 85% uptake rate by employing an intensive promotion campaign and other non-mandatory strategies concurrently [26]. However, the ability to deliver or maintain these intensive promotion campaigns is not always feasible in some hospital settings due to low resource or staffing levels or changes in priorities [18]. In the majority of hospitals, the decision to get vaccinated against influenza remains the personal choice of the healthcare worker (HCW). Hospitals and health departments in Australia promote the vaccine as being highly recommended but none have implemented any directives or policies requiring vaccination as a condition of employment. The choice to continue with conventional promotional strategies or move towards mandatory vaccine policies is highly debatable. Since 2006, there have been numerous case studies published in the United States highlighting the successful introduction of institutional policies that mandate influenza vaccination for HCWs. Virginia Mason Medical Centre was amongst the first hospitals to initiate mandatory influenza vaccination at their facility. Since that point, they have been able to achieve coverage rates of greater than 98%, with a less than 0.2% loss of staff over a four year period [13]. In 2008, Barnes Jewish Healthcare Consortium became the first health system to mandate vaccination and as a result achieved a vaccination rate of 98.4% [17]. In both cases, the policy did not include the use of declinations forms, but included termination of employment for failure to comply. Policies
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that terminate unvaccinated HCP have demonstrated success in immediately increasing vaccination coverage to near-universal levels at several large hospitals and healthcare systems [13,17,27]. In a review of the impact of hospital policies on HCW influenza vaccination rates, Nowalk et al. identified that changes in vaccination rates in hospitals with mandates (with consequences) was nearly double to that of hospitals with mandates without consequences (19.5 vs. 11%) [28]. Consequences for non-compliance usually include either a requirement to wear a mask, termination, additional education, and restriction from patient care duties and/or temporary suspension or unpaid leave. Not surprisingly, significantly lower declination rates have been associated with mandates with consequences (17.6 vs. 30.1%, respectively) compared with mandates without consequences [28]. However to date, very few hospitals have opted for such absolute measures. Rather most have instigated requirements along a continuum of increasing stringency, ranging from mandatory declination statements to consequences other than termination for vaccine refusal [29]. Modeling by leadership has been suggested as an approach to increase influenza vaccination rates among employees. When referring to modeling by leadership, we generally refer to leaders within hospitals or other healthcare settings; however, there may also be a role for professional medical societies or health bodies. For example, in the United States many of the professional medical societies have adopted an assertive and upfront position towards influenza vaccination. For example, The Society for Healthcare Epidemiology of America (SHEA), states explicitly in their position paper that HCWs have an ethical and professional duty to be vaccinated against possible transmission to patients, including influenza [30]. They advocate that influenza vaccination should be a condition of employment for all HCWs and redeployment repercussions should be designed for non-complying HCWs. Several other medical and health associations/societies including the American College of Physicians (ACP), the Infectious Disease Society of America (IDSA), the American Academy of Family Physicians (AAFP), the American Hospital Association (AHA) and the American Academy of Pediatrics (AAP) have all acknowledge with clear terminology that influenza vaccination should be mandatory for all HCWs [31]. While the impact of these position papers has not been measured; it sends a clear message out to HCWs and hospital management about the need for vaccination. These position papers can be used to support hospitals in implementing changes to their policies or for taking a stronger stance on non-compliance. To date, the majority of studies conducted on occupational influenza vaccination in Australia have examined the viewpoints of hospital or community-based HCWs towards influenza vaccination recommendations. Research focused on the attitudes of key healthcare stakeholders is relatively limited. This is one of the main strengths of the study. In addition, the high response rate and the use of in-depth interviews to elicit a greater depth in the information are also key strengths of our work. The following are noted as limitations: (1) interviews were only undertaken with a select group of participants, so the possibility of other important themes emerging cannot be ruled out; (2) the use of snowball recruitment may have also reduced the range of opinions amassed from participants; (3) specific details regarding the participants’ role was also not collected; and (4) we did not document whether the participant had received any previous funding from a pharmaceutical company. This was a small, qualitative study, and the findings should be explored further in larger, quantitative studies.
5. Conclusion Amongst the stakeholders interviewed, there was support for continuing to promote influenza vaccination for HCWs via
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conventional programs. However, we know that approaches such as the use of education programs, declination forms and mobile carts have their limitations and will not achieve the coverage rates advocated for. Based on our findings, we suggest that there is a need for our key stakeholders and policy makers to review the literature around the use of mandatory policies in the United States and reconsider whether the time for relying on conventional programs has passed. Given that the World Health Organisation has included HCWs as a target group for influenza vaccination, Australian hospitals may need to start considering the use of mandatory policies in the near future. There is recognition that vaccination is the central pillar to mitigating the impact of healthcare associated influenza and that further effort is needed to increase coverage. Acknowledgements The authors would like to thank all the stakeholders who participated in our study. Dr Holly Seale holds an NHMRC Australian-based Public Health Training Fellowship (1012631). References [1] The Australian Government Department of Health and Ageing. The Australian immunisation handbook. 10th ed. Canberra; 2013. [2] Maltezou HC, Tsakris A. Vaccination of health-care workers against influenza: our obligation to protect patients. Influenza Other Respi Viruses 2011;5:382–8. [3] Seale H, MacIntyre CR. Seasonal influenza vaccination in Australian hospital health care workers: a review. Med J Aust 2011;195:336–8. [4] Mereckiene J, Cotter S, Weber JT, Nicoll A, Levy-Bruhl D, Ferro A, et al. Low coverage of seasonal influenza vaccination in the elderly in many European countries. Euro Surveill 2008;13:19001. [5] Sheridan A BF, Pebody R. Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England. Department of Health, www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH 129849.; 2011. [6] National Advisory Committee on Immunisation (NACI). Canadian immunisation guide. 7th ed; 2006. [7] Seale H, Wang Q, Yang P, Dwyer DE, Wang X, Zhang Y, et al. Influenza vaccination amongst hospital health care workers in Beijing. Occup Med 2010;60:335–9. [8] Chor JSY, Pada SK, Stephenson I, Goggins WB, Tambyah PA, Clarke TW, et al. Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries. Vaccine 2011;29:7364–9. [9] Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel. Morb Mortal Wkly Rep 2011;60:1973–7. United States, 2010-11 influenza season. [10] Lugo NR. Will carrots or sticks raise influenza immunization rates of health care personnel. Am J Infect Control 2007;35:1–6. [11] Pearson ML, Bridges CB, Harper SA. Influenza vaccination of health-care personnel. Morb Mortal Wkly Rep 2006;55:1–16. Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). [12] Rebmann T, Wright KS, Anthony J, Knaup RC, Peters EB. Seasonal influenza vaccine compliance among hospital-based and nonhospital-based healthcare workers. Infect Cont Hosp Ep 2012;33:243–9.
[13] Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccination of healthcare workers: a 5-year study. Infect Cont Hosp Ep 2010;31:881–8. [14] Helms C, Polgreen P, Polgreen L, Evans T, Roberts LL, Clabaugh G, et al. Voluntary reporting of employee influenza vaccination rates by acute care hospitals in Iowa: the impact of a four year provider-based statewide performance improvement project. Vaccine 2011;29:3483–8. [15] Polgreen PM, Polgreen LA, Evans T, Helms C. A statewide system for improving influenza vaccination rates in hospital employees. Infect Cont Hosp Ep 2009;30:474–8. [16] Esolen LM, Kilheeney KL, Merkle RE, Bothe A. An alternate approach to improving healthcare worker influenza vaccination rates. Infect Cont Hosp Ep 2011;32:703–5. [17] Babcock HM, Gemeinhart N, Jones M, Dunagan WC, Woeltje KF. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis 2010;50:459–64. [18] Seale H, Kaur R, MacIntyre C. Understanding Australian healthcare workers’ uptake of influenza vaccination: examination of public hospital policies and procedures. BMC Health Serv Res 2012;12:325. [19] 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. [20] Tapiainen T, Bar G, Schaad UB, Heininger U. Influenza vaccination among healthcare workers in a university children’s hospital. Infect Cont Hosp Ep 2005;26:855–8. [21] Hollmeyer H, Hayden F, Mounts A, Buchholz U. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses 2013;7:604–21. [22] Thompson MG, McIntyre AF, Naleway AL, Black C, Kennedy ED, Ball S, et al. Potential influence of seasonal influenza vaccination requirement versus traditional vaccine promotion strategies on unvaccinated healthcare personnel. Vaccine 2013;31:3915–21. [23] Ottenberg AL, Wu JT, Poland GA, Jacobson RM, Koenig BA, Tilburt JC. Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate. Am J Public Health 2011;101:212–6. [24] Cadena J, Prigmore T, Bowling J, Ayala BA, Kirkman L, Parekh A, et al. Improving influenza vaccination of healthcare workers by means of quality improvement tools. Infect Cont Hosp Ep 2011;32:616–8. [25] Ofstead CL, Tucker SJ, Beebe TJ, Poland GA, Ofstead CL, Tucker SJ, et al. Influenza vaccination among registered nurses: information receipt, knowledge, and decision-making at an institution with a multifaceted educational program. Infect Cont Hosp Ep 2008;29:99–106. [26] Modak RM, Parris SM, Dilisi JP, Premkumar A. Increasing influenza vaccination rates among hospital employees without a mandatory policy. Infect Cont Hosp Ep 2012;33:1288–9. [27] Feemster KA, Prasad P, Smith MJ, Feudtner C, Caplan A, Offit P, et al. Employee designation and health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital. Vaccine 2011;29:1762–9. [28] Nowalk MP, Lin CJ, Raymund M, Bialor J, Zimmerman RK. Impact of hospital policies on health care workers’ influenza vaccination rates. Am J Infect Control 2013;41:697–701. [29] Polgreen PM, Septimus E, Talbot TR, Beekmann SE, Helms C. Results of a national survey of infectious diseases specialists regarding influenza vaccination programs for healthcare workers. Infect Cont Hosp Ep 2010;31:1063–5. [30] Talbot TR, Babcock H, Caplan AL, Cotton D, Maragakis LL, Poland GA, et al. Revised SHEA position paper: influenza vaccination of healthcare personnel. Infect Cont Hosp Ep 2010;31:987–95. [31] Kuehn BM. Mandatory influenza vaccination urged for clinicians, other health workers. J Am Med Assoc 2010;304:1545. Dr Holly Seale has previously received funding for investigator-driven research and invitations to present from GSK, Bio-CSL and Sanofi-Pasteur. This funding was not used for this study.
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Examining the views of key stakeholders regarding the provision of occupational influenza vaccination for healthcare workers in Australia Yi Chen Lim a , Holly Seale b,∗ a b
UNSW Medicine, University of New South Wales, New South Wales, Australia School of Public Health and Community Medicine, UNSW Medicine, University of New South Wales, New South Wales, Australia
a r t i c l e
i n f o
Article history: Received 20 August 2013 Received in revised form 6 November 2013 Accepted 15 November 2013 Available online 27 November 2013 Keywords: Healthcare workers Influenza Vaccination Hospitals
a b s t r a c t Annual vaccination of hospital healthcare workers (HCWs) may be an effective measure to reduce the transmission of healthcare associated influenza. However, vaccine coverage rates among HCWs in most public Australian hospitals are below satisfactory for a number of reasons. This study aimed to examine the opinions of key health stakeholders on current issues regarding HCW influenza vaccination. A qualitative study involving semi-structured interviews was undertaken with key Australian health stakeholders representing different organizations and sectors involved in influenza vaccination and policy. Amongst the participants, there was overwhelming support for HCW influenza vaccination. They viewed vaccination as one of the most important preventive measures for healthcare associated influenza and generally agreed that vaccination of HCWs reduces the overall risk of transmission to patients. However, there were contradictory attitudes regarding the evidence available for justifying the impact of vaccinating HCWs against influenza. Amongst the stakeholders interviewed, there was support for continuing to promote influenza vaccination for HCWs via the conventional framework. Participants recommended that hospitals continue to use conventional, voluntary strategies to increase vaccine coverage such as education and mobile carts. Given that the World Health Organization has included HCWs as a target group for influenza vaccination, Australian hospitals may need to start considering the use of mandatory policies in the near future. © 2013 Elsevier Ltd. All rights reserved.
1. Introduction As documented in the Australian immunisation handbook 10th Edition [1], all healthcare workers (HCWs), including staff and students directly involved in patient care or the handling of human tissues, are highly recommended to be vaccinated against influenza. The handbook proposes that healthcare employers should implement a comprehensive occupational vaccination program encompassing a vaccination policy, tracking of current staff vaccination records, provision of information about the relevant vaccinepreventable diseases, and the management of vaccine refusal (e.g., strategies to reduce the risk of a non-vaccinated HCW transmitting disease to vulnerable persons). Lastly, employers should take all reasonable steps to encourage non-immune workers to be vaccinated.
∗ Corresponding author at: School of Public Health & Community Medicine, Level 2, Samuels Building, Faculty of Medicine, University of New South Wales, Sydney 2052, Australia. Tel.: +61 2 9385 3129; fax: +61 2 9313 6185. E-mail addresses: [email protected] (Y.C. Lim), [email protected] (H. Seale). 0264-410X/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2013.11.063
Despite numerous attempts aimed at increasing acceptance, recorded coverage rates of seasonal influenza vaccination amongst hospital HCWs are poor and well below the 80% target recommended by the literature [2]. In a recent Australian study, the rates of HCW influenza vaccine coverage were found to be between 16.3 and 58.7% [3]. The findings from the Australian study upholds those from Europe, with documented rates ranging from 14.8 to 40.5% [4]. Whilst in the United Kingdom, despite recommendations by the Department of Health, uptake of seasonal flu vaccine was only 35% among frontline healthcare workers in 2011 [5]. Recent data from Canada, states that the vaccine coverage rates among HCWs ranges from 26 to 61% [6], while in Asia, lower levels of influenza vaccine uptake amongst HCWs have been documented in mainland China (18%) [7] and Hong Kong (30%) [8]. Lastly, while the CDC has reported that HCW influenza vaccination rates have steadily increased over the last decade in the United States [9], rates reported from different institutions remain low, with a national average of about 40% [10–12]. However, in recent years there has been a shift in coverage rates in some healthcare agencies or systems associated with the introduction of declination forms and/or mandatory vaccination policies [13], with some studies documenting increases in vaccination rates between 8.6 and 39.8% [14,15]. While rates of >90% have been
Y.C. Lim, H. Seale / Vaccine 32 (2014) 606–610
reported in hospitals that have mandated influenza vaccination [13,16,17]. In Australia, whether to provide free influenza vaccine to HCWs is a policy decision for each hospital or jurisdiction and is therefore, not uniform across the country. To the best of our knowledge, there has not been a shift to introduce any policies or stronger recommendations in hospitals across the country. While receiving the influenza vaccine is ‘highly recommended’ for Australian hospital HCWs; it is not an occupational requirement and hence, uptake remains low. In 2010, we undertook a qualitative study to examine the hospital policies and practices regarding occupational influenza vaccination of HCWs in Australia [18]. From the interviews conducted, it was clear that the hospitals were implementing multiple strategies to educate, promote, and deliver the vaccine to staff. However, resources and support were not always available to assist with the campaigns and the reality for many of the hospitals studied was that there was limited capacity to implement the vaccination campaigns at the levels high enough to raise compliance rates. Building on from that work, we were interested to find out the views of key stakeholders responsible for setting policy and agenda around occupational vaccination towards occupational influenza vaccination. 2. Methods
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interview. In addition, the interviewer used paraphrasing and additional questions to seek clarification. This ensured that the study included most of the topics and was flexible to changes depending on the actual scenario. Questions were also asked in an open-ended manner to allow room for expansion. For example, interviews often began with a broad question like “what are your thoughts about the use of the influenza vaccine in hospitals?” to allow participants to freely discuss their opinions. Prompts were only given when the interviewer deemed they were required to encourage the conversation back to topic. During the interviews, member checking was conducted to ensure that the ideas identified during the early phase of analysis were appropriate. HS conducted all interviews either in person (n = 1) or via telephone (n = 20).
2.4. Data analysis The interviews were digitally recorded, transcribed verbatim, and analysed thematically. Two investigators jointly developed the list of themes after one quarter of the transcripts had been analysed. An agreed framework was then applied to another sub-sample of transcripts and modified further. Using this final framework, all of the transcripts were analysed and coded. Text was organized within the identified themes of the developed framework without the use of any software.
2.1. Study design 3. Results Semi-structured interviews were undertaken with key leaders representing different health organizations and sectors in Australia to explore their opinions towards the provision of occupational influenza vaccination for HCWs. The Human Research Ethics Advisory Panel (social/medical) at the University of New South Wales reviewed and approved this study. 2.2. Participants Key healthcare stakeholders in this study were defined as individuals who are officially involved with policy making or the implementation of control strategies for communicable diseases including seasonal influenza in hospital environment. This principally encompassed personnel such as infection control officers, key infectious disease opinion leaders, and health department leaders. Participants were recruited to the study via two approaches. Firstly, an online search of health department websites was conducted to identify potential candidates matching the selection description. Each candidate was then followed up via email with an invitation letter. Secondly, interested candidates were asked to directly recommend any colleagues who would be willing to participate as well. Participants were only included into the study when full written consent had been received. An effort was made to recruit at least one participant from each of Australia’s states and territories in order to capture a broad range of views on issues affecting the country. This study did not collect any identifiable personal information from the participants. 2.3. Data collection An interview guide was jointly developed and reviewed by the researchers to identify key areas of interest for the study. This included a series of questions related to the following topics: general attitudes around the use of the influenza vaccine for HCWs, knowledge regarding the available evidence on vaccination, challenges associated with the current occupational vaccine provision system, and possible barriers and strategies in improving coverage. The list of topics served only as a general direction during each
Thirty-nine stakeholders were initially invited to participate in the study. Of those, 10 were non-contactable, five declined (as they believed they were not the appropriate person to be interviewed), while three were no longer in their positions. The remaining 21 stakeholders consented to participate and were interviewed. Participants included immunization managers/directors, senior medical advisors/officers from the health department, communicable disease directors, and public health nurses responsible for coordinating hospital campaigns. All states and territories of Australia were represented. The interview results are presented below according to the themes that were identified.
3.1. Core component of hospital health and safety agenda There was overwhelming support for HCW influenza vaccination amongst the participants. Influenza vaccination of HCWs was rated as being equally as important as staff complying with handhygiene and home quarantine to help protect against healthcare associated infections. Participants unanimously agreed that occupational influenza vaccination should be a core component of every hospital’s occupational safety agenda.
3.2. Influenza vaccine’s effectiveness and credibility of evidence While the current influenza vaccine was considered to be highly effective by some participants, others shared a more reserved view and classified the vaccine’s effectiveness as “moderate” or “debatable”. Participants agreed that there is currently a lack of published evidence supporting the impact of vaccinating staff against influenza in the hospital setting. It was suggested that this lack of high level evidence makes it difficult to convince some HCWs to get vaccinated, especially those who are medically trained. On the other hand, other participants reasoned that there is no dire need to obtain additional data to justify the use of the vaccine, given that it is a common belief that influenza vaccination of healthy adults is beneficial.
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“If we had more evidence to actually see that vaccinating the staff did reduce the transmission of disease to patients I think that it might be a bit easier for us. I think the more evidence that you have the better your case is. So although there’s evidence out there, and I’ve certainly seen some presentations and read articles to suggest that it does, particularly in residential aged care facilities, I don’t think there’s enough.” (Participant 2) “. . .. I certainly don’t think that there is any evidence that it’s not effective. It’s just an absence of evidence that it is effective. I mean obviously you can be vaccinated and not necessarily stop that, it’s not 100% effective. But given that there’s a [Health department] recommendation, and the professional duty, and occupational health and safety issues that are there, even if there isn’t evidence, I mean that’s not an argument for not doing it.” (Participant 12) “I don’t think that in actual fact that there is sufficient evidence upon which to actually persuade the skeptics. I’m not saying the skeptics are those people that are anti-immunization; I think it’s the skeptics that in actual fact are specifically the medical staff who are very analytical people, so therefore when you’re actually trying to actually use evidence as a means of mechanism of influencing people, I think that sometimes the evidence is a little rubbery.” (Participant 17)
3.3. Commitment and responsibility to occupational vaccination When asked to comment on the level of commitment being made by hospitals to increase staff influenza vaccination coverage, the responses were contradictory. While there were those who suggested that there was extreme variability across sites, others believed that Australian hospitals were doing all they could to promote the vaccine. However, it was suggested that within some institutions, the support for the influenza vaccination of staff was lacking from hospital directors or ward/department managers and that in some circles it may just be seen as an extra cost. A lack of collaboration and drive amongst the occupational health staff (i.e., those responsible for delivering the programs) was also suggested. “The hospital certainly supports it, and they actively encourage it . . . in a very small way. But there certainly could be more that could be done.” (Participant 19) “No, I think most of them aren’t doing enough and most of them think that they’re saving money by not getting everybody vaccinated. I mean, you know, they have to pay for the vaccination service, and, they see that as an upfront cost but if they do their sums and worked out the cost-benefit ratio in their terms of staff sickness, they wouldn’t be thinking that way, but generally there isn’t very much management support for good immunization programs.” (Participant 4) In comparison to the prevention of other healthcare associated infections or vaccine preventable diseases, participants thought that less attention was given to the prevention of healthcare associated influenza. Participants suggested that this may be associated with the fact that there is currently no national key performance indicator for occupational influenza vaccination. It was suggested that there is a boundary around how much the government can intervene to improve coverage. Furthermore, many participants commented that the structure of the Australian healthcare system currently is moving towards decentralization where hospitals are divided into local health districts to operate autonomously. In this setting, the role and influence of state government will probably further diminish.
3.4. Traditional barriers impact on uptake Access to the vaccine was proposed as the primary system barrier to increasing coverage in hospitals. In terms of resource factors such as issues around staffing levels and/or funding of the influenza vaccine, participants did not view these issues as particularly serious. Although, some agreed that more funding would benefit the situation, they also highlighted that the vaccines are cheap and are not too difficult to provide to the HCWs. 3.5. Reliance on the traditional measures to increase vaccine uptake Participants recommended that hospitals should continue to promote the use of conventional, voluntary strategies to increase vaccine coverage. Foremost, there was universal agreement that hospital promotion campaigns should primarily revolve around educating HCWs to overcome their attitudinal barriers. The need to promote to HCWs the benefits of regular influenza vaccination and their role in influenza transmission was emphasized, along with the need to dispel any misconceptions they have related to influenza vaccines. “I think education is the key; I think we need to be looking at how the education is delivered and I think we need to be asking the healthcare workers themselves how they would like to receive the information.” (Participant 2) Aside from needing to increase the amount of education provided to staff members, participants also highlighted that it was important to focus on the accessibility and logistical aspects of delivering the influenza vaccine to HCWs. Among the different strategies proposed, mobile vaccine carts was suggested to be the most effective means of improving accessibility. It was also recommended that hospitals should set up more vaccination clinics at convenient shifts for HCWs. Away from the more traditional approaches to increasing vaccination uptake; some participants recommenced the use of incentives or friendly competitions to increase vaccine rates. Lastly, it was also suggested that some form of role modeling should be considered as well for vaccine campaigns. 4. Discussion Using qualitative methods, this study explored the opinions of key health stakeholders on current issues regarding HCW influenza vaccination. Amongst our participants, there was overwhelming support for the need to vaccinate hospital HCWs against influenza. Participants proposed that hospitals should continue to use conventional promotion and delivery strategies in order to achieve their influenza vaccine targets. Participants highlighted the need to improve the: (1) approaches used to educate HCWs and (2) the strategies used to distribute the vaccine. Very few participants suggested that there was a need for restructuring the hospital directives towards a more regulated model. The most commonly suggested mechanism for improving vaccination rates was the use of education campaigns. Participants spoke of the need to promote to HCWs the benefits of regular influenza vaccination and their role in influenza transmission, along with the need to dispel any misconceptions they have related to influenza vaccines. In general, most studies show that campaigns encompassing multiple interventions including notification, education, and provision of vaccination simultaneously yield better results than those that only employ a single intervention [19]. Of these three approaches, the use of education has been found to be the key component of a successful campaign, with increased knowledge
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regarding influenza vaccination positively correlated with higher uptake rates among HCWs [20]. As advocated by Hollmeyer et al. a successful program must include culturally sensitive education on the risk of influenza and the overall benefits of vaccination, tailored to specific professional characteristics [21]. Finding the correct interventions to include in a promotion campaign can be difficult. In a recent study by Thompson et al. twelve vaccine promotion strategies were compared to examine the potential impact on the likelihood of being vaccinated [22]. From their survey of 1670 HCWs, they found that about half (47–60%) of the unvaccinated HCWs rated 10 of 12 interventions as having “neutral” or “no effect” on the likelihood they would be vaccinated next season. For all 12 interventions at least 1 in 7 unvaccinated HCWs reacted negatively, reporting that a given intervention would make them “less likely” to be vaccinated. A vaccine requirement was listed as the number one intervention that would make them more likely to be vaccinated next season. This was followed by a severity warning from the CDC regarding the upcoming season and receiving information about how the vaccine “reduces the chance of giving the flu to patients” and receiving information about the “risks of getting influenza from patients”. The intervention ranked as least likely to influence future uptake was having an “electronic appointment link, which allows you to pick date/time” and the requirement to “be vaccinated or sign a declination form”. In conclusion, it appeared that the information based interventions (aside from policy changes) appealed the most to both unvaccinated and vaccinated HCWs. [22]. While it is important to educate HCWs about the need for the flu vaccine and to also provide easily accessible locations for vaccinations, most sources suggest that conventional programs have their limitations [17,23]. In general, coverage from voluntary influenza vaccine programs are realistically capped at around 60%, which is evidently lower than compulsory vaccination programs [24]. Previous reports have described a “ceiling effect”, a seemingly maximized influenza vaccination coverage range above which further voluntary interventions are insufficient at increasing vaccine uptake [25]. Even multi-faceted quality improvement initiatives have hit similar ceilings, finding it difficult or impossible to raise and maintain annual vaccination coverage above 75%. In some rare instances, coverage rates close to or above 80% has been reported in settings, which have utilized non-mandatory campaigns. For example, Virginia Hospital Centre (VHC) in the United States managed to achieved a 85% uptake rate by employing an intensive promotion campaign and other non-mandatory strategies concurrently [26]. However, the ability to deliver or maintain these intensive promotion campaigns is not always feasible in some hospital settings due to low resource or staffing levels or changes in priorities [18]. In the majority of hospitals, the decision to get vaccinated against influenza remains the personal choice of the healthcare worker (HCW). Hospitals and health departments in Australia promote the vaccine as being highly recommended but none have implemented any directives or policies requiring vaccination as a condition of employment. The choice to continue with conventional promotional strategies or move towards mandatory vaccine policies is highly debatable. Since 2006, there have been numerous case studies published in the United States highlighting the successful introduction of institutional policies that mandate influenza vaccination for HCWs. Virginia Mason Medical Centre was amongst the first hospitals to initiate mandatory influenza vaccination at their facility. Since that point, they have been able to achieve coverage rates of greater than 98%, with a less than 0.2% loss of staff over a four year period [13]. In 2008, Barnes Jewish Healthcare Consortium became the first health system to mandate vaccination and as a result achieved a vaccination rate of 98.4% [17]. In both cases, the policy did not include the use of declinations forms, but included termination of employment for failure to comply. Policies
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that terminate unvaccinated HCP have demonstrated success in immediately increasing vaccination coverage to near-universal levels at several large hospitals and healthcare systems [13,17,27]. In a review of the impact of hospital policies on HCW influenza vaccination rates, Nowalk et al. identified that changes in vaccination rates in hospitals with mandates (with consequences) was nearly double to that of hospitals with mandates without consequences (19.5 vs. 11%) [28]. Consequences for non-compliance usually include either a requirement to wear a mask, termination, additional education, and restriction from patient care duties and/or temporary suspension or unpaid leave. Not surprisingly, significantly lower declination rates have been associated with mandates with consequences (17.6 vs. 30.1%, respectively) compared with mandates without consequences [28]. However to date, very few hospitals have opted for such absolute measures. Rather most have instigated requirements along a continuum of increasing stringency, ranging from mandatory declination statements to consequences other than termination for vaccine refusal [29]. Modeling by leadership has been suggested as an approach to increase influenza vaccination rates among employees. When referring to modeling by leadership, we generally refer to leaders within hospitals or other healthcare settings; however, there may also be a role for professional medical societies or health bodies. For example, in the United States many of the professional medical societies have adopted an assertive and upfront position towards influenza vaccination. For example, The Society for Healthcare Epidemiology of America (SHEA), states explicitly in their position paper that HCWs have an ethical and professional duty to be vaccinated against possible transmission to patients, including influenza [30]. They advocate that influenza vaccination should be a condition of employment for all HCWs and redeployment repercussions should be designed for non-complying HCWs. Several other medical and health associations/societies including the American College of Physicians (ACP), the Infectious Disease Society of America (IDSA), the American Academy of Family Physicians (AAFP), the American Hospital Association (AHA) and the American Academy of Pediatrics (AAP) have all acknowledge with clear terminology that influenza vaccination should be mandatory for all HCWs [31]. While the impact of these position papers has not been measured; it sends a clear message out to HCWs and hospital management about the need for vaccination. These position papers can be used to support hospitals in implementing changes to their policies or for taking a stronger stance on non-compliance. To date, the majority of studies conducted on occupational influenza vaccination in Australia have examined the viewpoints of hospital or community-based HCWs towards influenza vaccination recommendations. Research focused on the attitudes of key healthcare stakeholders is relatively limited. This is one of the main strengths of the study. In addition, the high response rate and the use of in-depth interviews to elicit a greater depth in the information are also key strengths of our work. The following are noted as limitations: (1) interviews were only undertaken with a select group of participants, so the possibility of other important themes emerging cannot be ruled out; (2) the use of snowball recruitment may have also reduced the range of opinions amassed from participants; (3) specific details regarding the participants’ role was also not collected; and (4) we did not document whether the participant had received any previous funding from a pharmaceutical company. This was a small, qualitative study, and the findings should be explored further in larger, quantitative studies.
5. Conclusion Amongst the stakeholders interviewed, there was support for continuing to promote influenza vaccination for HCWs via
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conventional programs. However, we know that approaches such as the use of education programs, declination forms and mobile carts have their limitations and will not achieve the coverage rates advocated for. Based on our findings, we suggest that there is a need for our key stakeholders and policy makers to review the literature around the use of mandatory policies in the United States and reconsider whether the time for relying on conventional programs has passed. Given that the World Health Organisation has included HCWs as a target group for influenza vaccination, Australian hospitals may need to start considering the use of mandatory policies in the near future. There is recognition that vaccination is the central pillar to mitigating the impact of healthcare associated influenza and that further effort is needed to increase coverage. Acknowledgements The authors would like to thank all the stakeholders who participated in our study. Dr Holly Seale holds an NHMRC Australian-based Public Health Training Fellowship (1012631). References [1] The Australian Government Department of Health and Ageing. The Australian immunisation handbook. 10th ed. Canberra; 2013. [2] Maltezou HC, Tsakris A. Vaccination of health-care workers against influenza: our obligation to protect patients. Influenza Other Respi Viruses 2011;5:382–8. [3] Seale H, MacIntyre CR. Seasonal influenza vaccination in Australian hospital health care workers: a review. Med J Aust 2011;195:336–8. [4] Mereckiene J, Cotter S, Weber JT, Nicoll A, Levy-Bruhl D, Ferro A, et al. Low coverage of seasonal influenza vaccination in the elderly in many European countries. Euro Surveill 2008;13:19001. [5] Sheridan A BF, Pebody R. Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England. Department of Health, www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH 129849.; 2011. [6] National Advisory Committee on Immunisation (NACI). Canadian immunisation guide. 7th ed; 2006. [7] Seale H, Wang Q, Yang P, Dwyer DE, Wang X, Zhang Y, et al. Influenza vaccination amongst hospital health care workers in Beijing. Occup Med 2010;60:335–9. [8] Chor JSY, Pada SK, Stephenson I, Goggins WB, Tambyah PA, Clarke TW, et al. Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among healthcare workers in three countries. Vaccine 2011;29:7364–9. [9] Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel. Morb Mortal Wkly Rep 2011;60:1973–7. United States, 2010-11 influenza season. [10] Lugo NR. Will carrots or sticks raise influenza immunization rates of health care personnel. Am J Infect Control 2007;35:1–6. [11] Pearson ML, Bridges CB, Harper SA. Influenza vaccination of health-care personnel. Morb Mortal Wkly Rep 2006;55:1–16. Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). [12] Rebmann T, Wright KS, Anthony J, Knaup RC, Peters EB. Seasonal influenza vaccine compliance among hospital-based and nonhospital-based healthcare workers. Infect Cont Hosp Ep 2012;33:243–9.
[13] Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccination of healthcare workers: a 5-year study. Infect Cont Hosp Ep 2010;31:881–8. [14] Helms C, Polgreen P, Polgreen L, Evans T, Roberts LL, Clabaugh G, et al. Voluntary reporting of employee influenza vaccination rates by acute care hospitals in Iowa: the impact of a four year provider-based statewide performance improvement project. Vaccine 2011;29:3483–8. [15] Polgreen PM, Polgreen LA, Evans T, Helms C. A statewide system for improving influenza vaccination rates in hospital employees. Infect Cont Hosp Ep 2009;30:474–8. [16] Esolen LM, Kilheeney KL, Merkle RE, Bothe A. An alternate approach to improving healthcare worker influenza vaccination rates. Infect Cont Hosp Ep 2011;32:703–5. [17] Babcock HM, Gemeinhart N, Jones M, Dunagan WC, Woeltje KF. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis 2010;50:459–64. [18] Seale H, Kaur R, MacIntyre C. Understanding Australian healthcare workers’ uptake of influenza vaccination: examination of public hospital policies and procedures. BMC Health Serv Res 2012;12:325. [19] 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. [20] Tapiainen T, Bar G, Schaad UB, Heininger U. Influenza vaccination among healthcare workers in a university children’s hospital. Infect Cont Hosp Ep 2005;26:855–8. [21] Hollmeyer H, Hayden F, Mounts A, Buchholz U. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Respir Viruses 2013;7:604–21. [22] Thompson MG, McIntyre AF, Naleway AL, Black C, Kennedy ED, Ball S, et al. Potential influence of seasonal influenza vaccination requirement versus traditional vaccine promotion strategies on unvaccinated healthcare personnel. Vaccine 2013;31:3915–21. [23] Ottenberg AL, Wu JT, Poland GA, Jacobson RM, Koenig BA, Tilburt JC. Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate. Am J Public Health 2011;101:212–6. [24] Cadena J, Prigmore T, Bowling J, Ayala BA, Kirkman L, Parekh A, et al. Improving influenza vaccination of healthcare workers by means of quality improvement tools. Infect Cont Hosp Ep 2011;32:616–8. [25] Ofstead CL, Tucker SJ, Beebe TJ, Poland GA, Ofstead CL, Tucker SJ, et al. Influenza vaccination among registered nurses: information receipt, knowledge, and decision-making at an institution with a multifaceted educational program. Infect Cont Hosp Ep 2008;29:99–106. [26] Modak RM, Parris SM, Dilisi JP, Premkumar A. Increasing influenza vaccination rates among hospital employees without a mandatory policy. Infect Cont Hosp Ep 2012;33:1288–9. [27] Feemster KA, Prasad P, Smith MJ, Feudtner C, Caplan A, Offit P, et al. Employee designation and health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital. Vaccine 2011;29:1762–9. [28] Nowalk MP, Lin CJ, Raymund M, Bialor J, Zimmerman RK. Impact of hospital policies on health care workers’ influenza vaccination rates. Am J Infect Control 2013;41:697–701. [29] Polgreen PM, Septimus E, Talbot TR, Beekmann SE, Helms C. Results of a national survey of infectious diseases specialists regarding influenza vaccination programs for healthcare workers. Infect Cont Hosp Ep 2010;31:1063–5. [30] Talbot TR, Babcock H, Caplan AL, Cotton D, Maragakis LL, Poland GA, et al. Revised SHEA position paper: influenza vaccination of healthcare personnel. Infect Cont Hosp Ep 2010;31:987–95. [31] Kuehn BM. Mandatory influenza vaccination urged for clinicians, other health workers. J Am Med Assoc 2010;304:1545. Dr Holly Seale has previously received funding for investigator-driven research and invitations to present from GSK, Bio-CSL and Sanofi-Pasteur. This funding was not used for this study.
