Influenza Vaccination: A Successful Outpatient Program Cheryl Lynn Walker, M.D.,* Roy Patterson, M.D.,* Anna Wu, M.D.,t and Elizabeth Bennett, R.N.*
ABSTRACT We initiated a program 10 evaluate patient reasons for refusing immunization in an allergy clinic. A general medicine clinic was sll/diedfor comparison. For the Northwestern University Allergy Service (NUAS) there were jive full-time salaried and seven voluntary physicians. In the general medicine clinic Ihere was one pari-lime salaried physician. FOllr hundred eighty-eight NUAS palients and 48 general medicine patients were evaluated. Ninef.v:/ive percent of the patients agreed to vaccination. E~r;gallergy, the only valid contraindicalion 10 influenza vaccinal ion, was reporled by Ihree «1%) patients. Transient mild symptoms consisting offatigue, myalgias, rhinitis and/or diarrhea were reported in 20% of the patie/1/s who received vaccination. No severe systemic reactions were reported. No significant difference in the vaccination acceptance rate was noted between the subspecialty and primary care olllPatient clinics. The importance q{ influenza immuni:ation in patients with asthma and in other high-risk poplllations deserves emphasis, and high success rates are achievahle when emphasized hy ph.vsicians. (Allergy Proc 13, 6:317-319, 1992)
O
ver twenty thousand deaths occur annually in the United States from complications associated with influenza virus infeetion.l Despite demonstrated efficacy and safety of the vaccine,2.3 significant underutilization has been reported. I The failure of physicians to recommend the vaccine and unfounded fears of physicians and patients adversely affect the success of
From the *Section of Allergy-Immunology and tSection of General Medicine, Department of Medicine, Northwestern University Medical School, Chicago, Illinois Address correspondence to Cheryl Lynn Walker, M.D., 30 N. Michigan Avenue, Suite 1824, Chicago, 1£ 60602
Allergy Proc.
influenza virus vaccination programs.4,5 Mail cues reminding patients to get vaccinated have been only mildly successful, increasing the vaccination rate from 30 to 39%.6 One vaccination program in hospitalized patients. which included attaching reminders to patient charts, achieved a 60% success rate.7 We report the surprising success of an outpatient influenza virus vaccination program, which involved attaching an influenza vaccination form to all charts routinely reminding physicians to recommend vaccination. Patient factors associated with refusing vaccination also were examined.
METHODS
I
nfluenza virus vaccination forms were attached to all charts of patients who presented either to the Northwestern University Allergy Service (NUAS) or to a general medicine outpatient clinic between September 18, 1989 and December 31, 1989 for evaluation (Fig. I). Patients met at least one of the following Centers for Disease Control (CDC) criteria 7: (1) persons aged 65 years or older, (2) persons with chronic cardiovascular or pulmonary disorders that have required medical attention within the past 12 months. (3) medical personnel who come into close contact with high-risk patients, or (4) persons with metabolic diseases, renal dysfunction, anemia, immunosuppression, or asthma. Patient age, diagnosis, and response to vaccination (accept/refuse) were recorded. Patients who refused vaccination were asked to explain why they refused. Patients who agreed to vaccination received a 0.5 mL intramuscular injection of F1uzone Influenza Virus Vaccine USP Trivalent Types A and B (Zonal Purified, Subvirion) (Connaught Laboratories. E.R. Squibb, Princeton, NJ). The vaccine contained the following three prototype strains: A/Taiwan/ I/86 (HINI), A/ Shanghai/II/8? (H3N2), and B/Yamagata/16/88. Pa-
317
Delivered by Ingenta to: Washington University School of Medicine Library IP: 5.62.152.202 On: Sat, 18 Jun 2016 07:24:52 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
Immunization
TABLE I
Questionnaire
U.S. Public Health Service recommendations for influenza immunization are as follows: 1. All persons aged >65 years, 2. persons with chronic cardiovascular or pulmonary disorders who have required medical attention within the past 12 months, 3. nursing home or chronic care facility residents, 4. medical personnel who come into contact with high-risk patients, 5. and persons with metabolic diseases, renal dysfunction anemia, immunosuppression, or asthma. Part A. To be completed by the physician for all patients who meet one or more of the above criteria.
Date
Patient Information Initial/Age/Diagnosis
Response Accept/Refuse
Comments: If Patient Refuses. List Reasons
Part B. To be completed by the nurse, if the patient agrees to immunization. Date of Immunization
Reactions
Patient Characteristics and Patient Response Influenza Vaccination
to
Allergy
Medicine
Number of patients Patients 65 years and older Primary diagnosis Asthma Diabetes mellitus Cardiovascular disease Renal disease Hypothyroidism Liver disease Malignancy Persons who work with elderly
488 48
48 28
461 0 0 0 0 0 0 0
2 6 2 I 2 I 5 I
Accepted Refused
464 24
45
Figure J. fnJluenza Vaccination Form
tients were asked to notify the NUAS of all and any complications associated with vaccination. To determine whether the experience of the allergy subspecialty clinic was comparable with that of a primary care clinic, we evaluated patients who presented to a general medicine outpatient clinic in a similar fashion. RESULTS ive hundred thirty-six patients who presented either to the Northwestern Allergy clinic (488) or the general medicine clinic (48) met one of the CDC criteria outlined in Figure 1. There were five full-time salaried and seven voluntary physicians in the NUAS clinic and one part-time salaried physician in the general medicine clinic. Five hundred nine patients (95%) accepted vaccination (Table I). Twenty-seven patients (5%) refused vaccination. In most instances, no specific reason was given for refusal of vaccination (Table II). Three patients reported a history of egg allergy. Five patients refused vaccination because of symptoms associated with previous vaccination. No significant difference between the acceptance rates of the allergy clinic and general medicine clinic was noted (the 95% confidence interval for the difference in acceptance rates was between 0.028 and 0.(02). Seventy of the 488 (12%) patients reported adverse reactions to vaccination (Table III). Tenderness and erythema at the site of injection were reported in 39 (89%) patients. Transient systemic symptoms of myalgias, low-grade fever, and fatigue were reported in 11 (2%) patients. No Severe systemic reactions were reported. None of the patients who received vaccination in the general medicine clinic reported adverse reactions.
F
318
3
DISCUSSION
N
inety-five percent of the patients evaluated in this study agreed to vaccination. This rate is significantly better than the 30% influenza vaccination rate reported nationally and the 39% vaccination rate reported with mail cues.6 Of the patients who refused, only a small percentage of patients (4%) reported egg allergy, the only valid contraindication to influenza vaccination. Fears of becoming ill with the vaccine adversely affected patient response to vaccination.
TABLE II Reasons for Refusing Vaccination Reason Total I. No specific reason given
2. Egg allergy 3. Pregnant 4. Symptoms associated with last vaccination No specific symptoms noted Vomiting Throat tightness Rhinitis "Never get the flu" Fear Do not like injections
November-December
Allergy Clinic
Medicine Clinic
24 II I
3 0 0 0
2
0
I I 0 3 I I
0 0 2 I 0 0
3
1992, Vol. 13, No.6
Delivered by Ingenta to: Washington University School of Medicine Library IP: 5.62.152.202 On: Sat, 18 Jun 2016 07:24:52 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
TABLE III
Patient Reported Symptoms Associated with Influenza Vaccination Symptom Local (erythema, or swelling) Rhinitis Headache Asthma flare Fatigue Nausea Myalgias Fever Pruritus
tenderness,
Number of Patients 39 20
7 5 4 4
4 4
I
As expected, influenza vaccination in this population was not associated with any severe adverse reactions. Less than 5% of the patients experienced systemic symptoms, and when they did occur, the reactions were transient mild symptoms of fatigue or gastrointestinal discomfort. Although asthma exacerbation was reported by four patients, the association is probably more coincidental than causa1.8 As expected, no severe systemic allergic reactions were reported. Concern regarding the safety of influenza vaccination increased in 1976, when Guillain-Barre Syndrome was associated with the swine flu vaccine. However, the risk of Guillain-Barre syndrome was eliminated with the subsequent omission of the swine antigen from the vaccine.8 In conclusion, the findings of this study suggest that physician commitment to vaccination may be the single most important factor influencing the success rate of vaccination. Physician reluctance to encourage vaccination may result from doubt regarding the efficacy of the vaccine.9 In recent years, the efficacy of influenza vaccination has been debated in the literature.IO•11 However, despite some variation with efficacy as a result of antigenic drift, 12 influenza vaccination remains approximately 70% effective.2 Furthermore, vaccination clearly is associated with decreased morbidity, mortality, and medical care cost associated with influenza virus infection.13,14 Therefore, influenza vaccination should be encouraged for all high-risk persons. The majority of the patients who participated in this study had asthma and were receiving care in the allergy
clinic. Although we concurrently evaluated patients who presented to a primary care service, the numbers of patients admittedly were small. Thus, whether a similar program would be effective in a nonasthmatic population is unclear. However, the findings of this study do suggest that a vaccination program that involves attaching vaccination forms to all patient charts, which not only educates the physician but also routinely reminds the physician to offer vaccination to all high risk patients, may significantly improve influenza vaccine utilization. This study was supported by the NIAID Grant A 11403 and by the Ernest S. Bazley Fund.
REFERENCES 1. Center for Disease Control. Influenza activity-worldwideand influenza vaccine availability-United States. MMWR 559:600, 1988. 2. Ward AE, Harcus AW, Bryett KA, et a!. Influenza vaccine: The effects of the 1980/1987 viral strains. CUIT Med Res Opin 10:414-421,1987. 3. Meyer HM, Hopps HE, Parkman PO, Ennis FA. Review of existing vaccines for influenza. Am J C1in Pathol 70: 146-152. 1978. 4. Ruben FL. New concepts in the control of influenza. Compr Ther 13:9-12,1987. 5. Poland GA. Influenza and pneumococcal vaccines. Postgrad Med 84:26, 1988. 6. Center for Disease Control, Department of Health and Human Services: Prevention and control of influenza. Recommendation of the Immunization Practices Advisory Committee. Ann Intern Med 101:218-222, 1984. 7. Nichol KL, Korn JE, Margolis KL, et a!. Achieving a National Health Objective for influenza immunization; success of an institution-wide vaccination program. Am J Med 89: 156-60, 1990. 8. Margolis KM, Poland GA, McPherson OS, et al. Incidence of adverse reactions following influenza vaccination. Clin Res 36:7-15A,1988. 9. Pachucki CT, Pappas SA, Fuller GF, et a!. Influenza A among hospital personnel and patients: implications for recognition, prevention, and control. Arch Intern Med 149:77-80, 1989. 10. Heun EM, Vogt RL, Birkhead GS. Influenza A in nursing homes. Am J Public Health 76:1460-1461,1986. II. Berk SL, Alvarez S. Vaccinating the elderly. Recommendation and rationale. Geriatrics 41 :79-83, 1986. 12. Glezen WP. Serious morbidity and mortality associated with influenza epidemics. Epidemiol Rev 4:25-44, 1982. 13. Helliwell BE, Drummond ME The costs and benefits of preventing influenza in Ontario's elderly. Can J Public Health 79:175-180,1988. 14. Barker NH, Mullooly JP. Influenza vaccination of elderly persons: Reduction in pneumonia and influenza hospitalizations and deaths. JAMA 244:2547-2549, 1980. 15. Mullooly JP. Increasing influenza vaccination among high-risk elderly. A randomized controlled trial ofa mail cue in an HMA setting. Am J Public Health 77:626-627, 1987. 0
Allergy Proc. 319 Delivered by Ingenta to: Washington University School of Medicine Library IP: 5.62.152.202 On: Sat, 18 Jun 2016 07:24:52 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
ABSTRACT We initiated a program 10 evaluate patient reasons for refusing immunization in an allergy clinic. A general medicine clinic was sll/diedfor comparison. For the Northwestern University Allergy Service (NUAS) there were jive full-time salaried and seven voluntary physicians. In the general medicine clinic Ihere was one pari-lime salaried physician. FOllr hundred eighty-eight NUAS palients and 48 general medicine patients were evaluated. Ninef.v:/ive percent of the patients agreed to vaccination. E~r;gallergy, the only valid contraindicalion 10 influenza vaccinal ion, was reporled by Ihree «1%) patients. Transient mild symptoms consisting offatigue, myalgias, rhinitis and/or diarrhea were reported in 20% of the patie/1/s who received vaccination. No severe systemic reactions were reported. No significant difference in the vaccination acceptance rate was noted between the subspecialty and primary care olllPatient clinics. The importance q{ influenza immuni:ation in patients with asthma and in other high-risk poplllations deserves emphasis, and high success rates are achievahle when emphasized hy ph.vsicians. (Allergy Proc 13, 6:317-319, 1992)
O
ver twenty thousand deaths occur annually in the United States from complications associated with influenza virus infeetion.l Despite demonstrated efficacy and safety of the vaccine,2.3 significant underutilization has been reported. I The failure of physicians to recommend the vaccine and unfounded fears of physicians and patients adversely affect the success of
From the *Section of Allergy-Immunology and tSection of General Medicine, Department of Medicine, Northwestern University Medical School, Chicago, Illinois Address correspondence to Cheryl Lynn Walker, M.D., 30 N. Michigan Avenue, Suite 1824, Chicago, 1£ 60602
Allergy Proc.
influenza virus vaccination programs.4,5 Mail cues reminding patients to get vaccinated have been only mildly successful, increasing the vaccination rate from 30 to 39%.6 One vaccination program in hospitalized patients. which included attaching reminders to patient charts, achieved a 60% success rate.7 We report the surprising success of an outpatient influenza virus vaccination program, which involved attaching an influenza vaccination form to all charts routinely reminding physicians to recommend vaccination. Patient factors associated with refusing vaccination also were examined.
METHODS
I
nfluenza virus vaccination forms were attached to all charts of patients who presented either to the Northwestern University Allergy Service (NUAS) or to a general medicine outpatient clinic between September 18, 1989 and December 31, 1989 for evaluation (Fig. I). Patients met at least one of the following Centers for Disease Control (CDC) criteria 7: (1) persons aged 65 years or older, (2) persons with chronic cardiovascular or pulmonary disorders that have required medical attention within the past 12 months. (3) medical personnel who come into close contact with high-risk patients, or (4) persons with metabolic diseases, renal dysfunction, anemia, immunosuppression, or asthma. Patient age, diagnosis, and response to vaccination (accept/refuse) were recorded. Patients who refused vaccination were asked to explain why they refused. Patients who agreed to vaccination received a 0.5 mL intramuscular injection of F1uzone Influenza Virus Vaccine USP Trivalent Types A and B (Zonal Purified, Subvirion) (Connaught Laboratories. E.R. Squibb, Princeton, NJ). The vaccine contained the following three prototype strains: A/Taiwan/ I/86 (HINI), A/ Shanghai/II/8? (H3N2), and B/Yamagata/16/88. Pa-
317
Delivered by Ingenta to: Washington University School of Medicine Library IP: 5.62.152.202 On: Sat, 18 Jun 2016 07:24:52 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
Immunization
TABLE I
Questionnaire
U.S. Public Health Service recommendations for influenza immunization are as follows: 1. All persons aged >65 years, 2. persons with chronic cardiovascular or pulmonary disorders who have required medical attention within the past 12 months, 3. nursing home or chronic care facility residents, 4. medical personnel who come into contact with high-risk patients, 5. and persons with metabolic diseases, renal dysfunction anemia, immunosuppression, or asthma. Part A. To be completed by the physician for all patients who meet one or more of the above criteria.
Date
Patient Information Initial/Age/Diagnosis
Response Accept/Refuse
Comments: If Patient Refuses. List Reasons
Part B. To be completed by the nurse, if the patient agrees to immunization. Date of Immunization
Reactions
Patient Characteristics and Patient Response Influenza Vaccination
to
Allergy
Medicine
Number of patients Patients 65 years and older Primary diagnosis Asthma Diabetes mellitus Cardiovascular disease Renal disease Hypothyroidism Liver disease Malignancy Persons who work with elderly
488 48
48 28
461 0 0 0 0 0 0 0
2 6 2 I 2 I 5 I
Accepted Refused
464 24
45
Figure J. fnJluenza Vaccination Form
tients were asked to notify the NUAS of all and any complications associated with vaccination. To determine whether the experience of the allergy subspecialty clinic was comparable with that of a primary care clinic, we evaluated patients who presented to a general medicine outpatient clinic in a similar fashion. RESULTS ive hundred thirty-six patients who presented either to the Northwestern Allergy clinic (488) or the general medicine clinic (48) met one of the CDC criteria outlined in Figure 1. There were five full-time salaried and seven voluntary physicians in the NUAS clinic and one part-time salaried physician in the general medicine clinic. Five hundred nine patients (95%) accepted vaccination (Table I). Twenty-seven patients (5%) refused vaccination. In most instances, no specific reason was given for refusal of vaccination (Table II). Three patients reported a history of egg allergy. Five patients refused vaccination because of symptoms associated with previous vaccination. No significant difference between the acceptance rates of the allergy clinic and general medicine clinic was noted (the 95% confidence interval for the difference in acceptance rates was between 0.028 and 0.(02). Seventy of the 488 (12%) patients reported adverse reactions to vaccination (Table III). Tenderness and erythema at the site of injection were reported in 39 (89%) patients. Transient systemic symptoms of myalgias, low-grade fever, and fatigue were reported in 11 (2%) patients. No Severe systemic reactions were reported. None of the patients who received vaccination in the general medicine clinic reported adverse reactions.
F
318
3
DISCUSSION
N
inety-five percent of the patients evaluated in this study agreed to vaccination. This rate is significantly better than the 30% influenza vaccination rate reported nationally and the 39% vaccination rate reported with mail cues.6 Of the patients who refused, only a small percentage of patients (4%) reported egg allergy, the only valid contraindication to influenza vaccination. Fears of becoming ill with the vaccine adversely affected patient response to vaccination.
TABLE II Reasons for Refusing Vaccination Reason Total I. No specific reason given
2. Egg allergy 3. Pregnant 4. Symptoms associated with last vaccination No specific symptoms noted Vomiting Throat tightness Rhinitis "Never get the flu" Fear Do not like injections
November-December
Allergy Clinic
Medicine Clinic
24 II I
3 0 0 0
2
0
I I 0 3 I I
0 0 2 I 0 0
3
1992, Vol. 13, No.6
Delivered by Ingenta to: Washington University School of Medicine Library IP: 5.62.152.202 On: Sat, 18 Jun 2016 07:24:52 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
TABLE III
Patient Reported Symptoms Associated with Influenza Vaccination Symptom Local (erythema, or swelling) Rhinitis Headache Asthma flare Fatigue Nausea Myalgias Fever Pruritus
tenderness,
Number of Patients 39 20
7 5 4 4
4 4
I
As expected, influenza vaccination in this population was not associated with any severe adverse reactions. Less than 5% of the patients experienced systemic symptoms, and when they did occur, the reactions were transient mild symptoms of fatigue or gastrointestinal discomfort. Although asthma exacerbation was reported by four patients, the association is probably more coincidental than causa1.8 As expected, no severe systemic allergic reactions were reported. Concern regarding the safety of influenza vaccination increased in 1976, when Guillain-Barre Syndrome was associated with the swine flu vaccine. However, the risk of Guillain-Barre syndrome was eliminated with the subsequent omission of the swine antigen from the vaccine.8 In conclusion, the findings of this study suggest that physician commitment to vaccination may be the single most important factor influencing the success rate of vaccination. Physician reluctance to encourage vaccination may result from doubt regarding the efficacy of the vaccine.9 In recent years, the efficacy of influenza vaccination has been debated in the literature.IO•11 However, despite some variation with efficacy as a result of antigenic drift, 12 influenza vaccination remains approximately 70% effective.2 Furthermore, vaccination clearly is associated with decreased morbidity, mortality, and medical care cost associated with influenza virus infection.13,14 Therefore, influenza vaccination should be encouraged for all high-risk persons. The majority of the patients who participated in this study had asthma and were receiving care in the allergy
clinic. Although we concurrently evaluated patients who presented to a primary care service, the numbers of patients admittedly were small. Thus, whether a similar program would be effective in a nonasthmatic population is unclear. However, the findings of this study do suggest that a vaccination program that involves attaching vaccination forms to all patient charts, which not only educates the physician but also routinely reminds the physician to offer vaccination to all high risk patients, may significantly improve influenza vaccine utilization. This study was supported by the NIAID Grant A 11403 and by the Ernest S. Bazley Fund.
REFERENCES 1. Center for Disease Control. Influenza activity-worldwideand influenza vaccine availability-United States. MMWR 559:600, 1988. 2. Ward AE, Harcus AW, Bryett KA, et a!. Influenza vaccine: The effects of the 1980/1987 viral strains. CUIT Med Res Opin 10:414-421,1987. 3. Meyer HM, Hopps HE, Parkman PO, Ennis FA. Review of existing vaccines for influenza. Am J C1in Pathol 70: 146-152. 1978. 4. Ruben FL. New concepts in the control of influenza. Compr Ther 13:9-12,1987. 5. Poland GA. Influenza and pneumococcal vaccines. Postgrad Med 84:26, 1988. 6. Center for Disease Control, Department of Health and Human Services: Prevention and control of influenza. Recommendation of the Immunization Practices Advisory Committee. Ann Intern Med 101:218-222, 1984. 7. Nichol KL, Korn JE, Margolis KL, et a!. Achieving a National Health Objective for influenza immunization; success of an institution-wide vaccination program. Am J Med 89: 156-60, 1990. 8. Margolis KM, Poland GA, McPherson OS, et al. Incidence of adverse reactions following influenza vaccination. Clin Res 36:7-15A,1988. 9. Pachucki CT, Pappas SA, Fuller GF, et a!. Influenza A among hospital personnel and patients: implications for recognition, prevention, and control. Arch Intern Med 149:77-80, 1989. 10. Heun EM, Vogt RL, Birkhead GS. Influenza A in nursing homes. Am J Public Health 76:1460-1461,1986. II. Berk SL, Alvarez S. Vaccinating the elderly. Recommendation and rationale. Geriatrics 41 :79-83, 1986. 12. Glezen WP. Serious morbidity and mortality associated with influenza epidemics. Epidemiol Rev 4:25-44, 1982. 13. Helliwell BE, Drummond ME The costs and benefits of preventing influenza in Ontario's elderly. Can J Public Health 79:175-180,1988. 14. Barker NH, Mullooly JP. Influenza vaccination of elderly persons: Reduction in pneumonia and influenza hospitalizations and deaths. JAMA 244:2547-2549, 1980. 15. Mullooly JP. Increasing influenza vaccination among high-risk elderly. A randomized controlled trial ofa mail cue in an HMA setting. Am J Public Health 77:626-627, 1987. 0
Allergy Proc. 319 Delivered by Ingenta to: Washington University School of Medicine Library IP: 5.62.152.202 On: Sat, 18 Jun 2016 07:24:52 Copyright (c) Oceanside Publications, Inc. All rights reserved. For permission to copy go to https://www.oceansidepubl.com/permission.htm
