Influenza vaccination in Turkey: prevalence of risk groups, current vaccination status, factors influencing vaccine uptake and steps taken to increase vaccination rate

Frequency of Asthma Exacerbations and Upper Respiratory Tract Infections Among Adults With Asthma According to Vaccination Status: Does the annual influenza vaccine have a protective effect?

Objectives

Annual influenza vaccinations are recommended for asthma patients to prevent seasonal influenza and influenza-triggered asthma exacerbations. However, data on the beneficial effect of this vaccine on the frequency of asthma exacerbations are conflicting. Therefore, this study aimed to assess the effectiveness of the influenza vaccine in terms of reducing the frequency of asthma-related exacerbations and upper respiratory tract infections among adult patients with asthma.

Methods

This retrospective cohort study was performed from January to December 2018 in Muscat Governorate, Oman. A total of 466 patients attending 9 randomly selected primary health centres in Muscat Governorate were enrolled in the study and followed up for one year post vaccination.

Results

Most of the patients were female (70.6%) and had moderate persistent asthma (42.9%). There were 203 patients (43.6%) in the vaccinated group and 263 patients (56.4%) in the non-vaccinated group. A proportion of patients in each group had allergic rhinitis (28.6% and 25.5%, respectively). The frequency of upper respiratory tract infections over the one-year follow-up period was significantly lower in the vaccinated group than in the non-vaccinated group (37.9% versus 73%; relative risk [RR]: 2.299; 95% confidence interval [CI]: 1.834-2.882; P <0.001); however, there was no significant difference in terms of the frequency of asthma exacerbations (41.9% versus 45.2%; RR: 0.925; 95% CI: 0.750-1.141; P >0.050).

Conclusion

The influenza vaccine significantly reduces the frequency of upper respiratory tract infections over the following year. However, it does not significantly reduce the frequency of asthma exacerbations among Omani adults with asthma. Further studies are recommended to support the protective effect of the vaccine in this regard.

Influenza vaccination knowledge, attitudes, and practices among Tunisian elderly with chronic diseases

BACKGROUND

Generally, seasonal influenza does not cause severe infection in healthy adults, but for the elderly, an infection can pose a serious health concern. Although several measures can help prevent influenza, vaccination is considered the most effective. This study aimed to assess influenza vaccine uptake among elderly with chronic diseases in Tunisia during the 2018-2019 influenza season, and to identify knowledge, attitudes and barriers associated with influenza vaccine uptake.

METHODS

During influenza season of 2018-2019, we conducted a national cross-sectional study among elderly with chronic disease who were attending primary and secondary health care facilities in Tunisia. We collected data regarding practices, general knowledge and attitudes related to influenza and influenza vaccine, using a standardized questionnaire. A multivariate analysis by logistic regression was performed to assess the factors influencing willingness to receive influenza vaccine.

RESULTS

Among the 1191 surveyed elderly, 19.4% (95%CI 14.1-21.9) were vaccinated during the 2018-2019 influenza season and 64.7% (61.9-67.3) expressed willingness to be vaccinated in the next season regardless of vaccination status in the 2018-2019 season. Previous vaccination in the 2018-2019 influenza season was the most significantly associated factor with willingness to receive influenza vaccine (adjusted OR = 16.5 [3.7-72.4]). Significant associations were also observed between knowledge of influenza severity for the elderly as well as for those with chronic diseases and willingness to be vaccinated (p < 0.01). Likewise, participants who were convinced by flu vaccine effectiveness and those who were not concerned about vaccine side effects were more likely to be vaccinated (p < 0.001). The main reason that may lead to vaccine acceptance was a doctor's recommendation (41.1%), while the two main reasons that may lead to vaccine refusal were concerns about side effects (71.5%) and a belief that vaccine was ineffective in averting influenza illness (33.9%). Doctors were the most trusted source for information about influenza vaccine (91.5%).

CONCLUSION

Our study revealed low influenza vaccination coverage among Tunisian elderly with chronic diseases believed to be at higher risk for severe acute respiratory infections and death if infected with influenza. Treating physicians' role in promoting influenza vaccination in this high-risk group seems to be crucial.

Clinical Audit on Chronic Obstructive Pulmonary Disease (COPD) Management in Primary Care: A Quality Improvement Project from Hong Kong

Objective

To enhance the quality of COPD management in primary care via a two-phase clinical audit in Hong Kong.

Methods

COPD patients aged 40 or above and had attended any of the 73 public primary care clinics under the Hospital Authority of Hong Kong (HAHK) for follow up (FU) during the audit period were included. Performance of six evidence-based audit criteria on COPD care was reviewed in phase 1 from 1st April 2017 to 31st March 2018. Service gaps were identified and a series of quality improvement strategies were executed in the one-year implementation phase. The outcome of the service enhancement was assessed in phase 2 from 1st April 2019 to 31st March 2020. Student’s t-test and the chi-square test were used to examine the statistically significant differences between the two phases.

Results

Totally 10,385 COPD cases were identified in phase 1, the majority were male (87.7%) and the mean age was 75.3±9.9 years. Among the 3102 active smokers, 1788 (57.6%) were referred to receive the smoking cessation counselling and 1578 (50.9%) actually attended it. A total of 4866 cases (46.9%) received seasonal influenza vaccine (SIV) and 4227 cases (40.7%) received pneumococcal vaccine (PCV). A total of 1983 patients (19.1%) had spirometry test done before and 1327 patients (12.8%) had history of hospital admission due to acute exacerbation of COPD (AECOPD). After the proactive implementation phase, performance on all criteria was significantly improved in phase 2, with a marked increase in the SIV and PCV uptake rate and spirometry performance rate. Most importantly, a significant reduction in AECOPD rate leading to hospital admission had been achieved (9.6%, P<0.00001).

Conclusion

COPD care at all public primary care clinics of HAHK had been significantly improved for all audit criteria via the systematic team approach, which, in turn, reduced the hospital admission rate and helped relieve the burden of the health care system.

Characteristics, Management and In-Hospital Clinical Outcomes Among Inpatients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in China: Results from the Phase I Data of ACURE Study

PURPOSE

The study aimed to give a comprehensive overview of characteristics and evaluate in-hospital clinical outcomes among hospitalized acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients in China using data from the AECOPD inpatient registry (ACURE).

PATIENTS AND METHODS

The ACURE is an ongoing, national, multicenter, observational registry. Participants enrolled during phase I stage (1st September 2017 to 25th February 2020) of ACURE with confirmed AECOPD diagnoses were studied. Descriptive analyses were conducted to describe features and occurrences of in-hospital clinical outcomes of AECOPD inpatients in real-world China.

RESULTS

A total of 5334 AECOPD inpatients from 163 sites in 28 provinces or province-level municipalities were included. Among all participants, 78.8% were males and the median age was 69.0 [interquartile range (IQR): 63.0-76.0] years. The proportions of current and former smokers were 23.6% and 44.2%, respectively. The median age at COPD diagnosis was 64.0 (IQR: 57.0-71.0) years and 88.7% participants demonstrated at least one comorbidity. During stable period, only 56.9% subjects received pharmacological therapies and the influenza vaccination rate was 2.9%. During hospitalization, 99.5% subjects received pharmacological treatments and antibiotics were prescribed to 90.9% participants. The all-cause in-hospital mortality was 0.1% and no significant difference was found across hospital categories.

CONCLUSION

Clinical features of Chinese AECOPD inpatients were different from those of other populations. In real-world China, the clinical management during stable period was unsatisfied, whereas therapy during hospitalization was effective regarding in-hospital clinical outcomes regardless of hospital category.

Outcome predictors of influenza for hospitalization and mortality in children

Severity of disease caused by influenza virus and the influencing factors that may be different. Moreover, the disease course actually may not be determined specifically in children because of lower seroprotection rates of children. Herein, the results clinic and outcome data of children with influenza from Turkey were reported. We present here the results from 2013 to 2017. Nasopharyngeal swab samples of the children with influenza were investigated via multiplex polymerase chain reaction. A total of 348 children were diagnosed with influenza; 143 (41.1%) were influenza A, 85 (24.4%) were influenza B, and 120 (34.5%) were mixt infection with other respiratory viruses. Fifty‐four percent of children admitted to intensive care unit (ICU) were under 2 years of age (p = .001). Having an underlying disease was detected as the main predictor for both hospitalization and ICU stay according to multiple logistic regression analysis (odds ratio [OR], 11.784: 95% confidence interval [CI], 5.212–26.643; p = .001 and OR, 4.972: 95% CI, 2.331–10.605; p = .001, respectively). Neurological symptoms most frequently seen in cases who died (44.4%; p = .02). Lymphopenia was relatively higher (55.6%) and thrombocytopenia was most frequently seen in cases who died (77.8%) with a significant ratio (p = .001). Underlying diseases was found a risk factor for influenza being hospitalized and being admitted to ICU. Children under 2 years of age and with underlying diseases should be vaccinated particularly in countries where the influenza vaccination is still not routinely implemented in the immunization schedule.

Highlights Underlying diseases is a risk factor for influenza to be hospitalized and admitted to ICU. Influenza vaccination is of great importance to prevent life‐threatening complications of influenza, particularly in children require ICU admission. The possibility to reduce the outpatient visit number by vaccination has a great impact on disease burden in addition to the underestimated crucial social benefits, as well.

Determining Significant Factors Affecting Vaccine Demand and Factor Relationships Using Fuzzy DEMATEL Method

Even though deadly effects of outbreaks such as SARS, H1N1, EBOLA and COVID-19 took the attention of the community, generating 100% vaccination uptake from people who are expected to be affected by such outbreaks is almost impossible. Hence, determining the actual vaccine demand for typical viruses and reaching this population are becoming important issues to prevent from spreading such viruses like wildfire. Many countries have been forecasting vaccine demand according to birth rates. However, factors such as district-level per capita income, literacy rate, urbanization, and some other factors should also be considered for more accurate forecasts. There is another factor affecting countries’ vaccine demand; some of the vaccines that WHO recommends are included in the national immunization programs, while others are only recommended. Thus, this study first aims to explore the most significant factors that affect the demand of vaccines that are not included in national immunization campaigns then to present the cause and effect relationships among the factors using the fuzzy DEMATEL method to provide insights to managers for better vaccine demand forecast and to increase vaccine uptake. According to the analysis results, immunization related beliefs is the most important factor among others included in this research.

Prevalence of influenza and pneumococcal vaccination in chronic obstructive pulmonary disease patients in association with the occurrence of acute exacerbations

Background

Based on current evidence, vaccination is recommended against the influenza virus and pneumococcus to avoid serious acute exacerbations in patients with chronic obstructive pulmonary disease (COPD), but the rate of their vaccination coverage is still suboptimal. To determine the prevalence and effectiveness of influenza and pneumococcal vaccination in COPD patients, and to prove its hypothetical association with the decreasing number of acute exacerbations.

Methods

We conducted a retrospective, population-based cohort study. Influenza and pneumococcal vaccination history were collected from 250 patients selected by simple random sampling from all COPD patients in Budapest at the Department of Pulmonary Rehabilitation of the National Koranyi Institute of Pulmonology between 01 January 2019 and 01 June 2019. Inclusion criteria were the following: age 40 years and diagnosis of COPD. Odds ratios (ORs) were evaluated based on the occurrence of acute exacerbations during the preceding year.

Results

The average age was 66.62 (±8.34) years, 67.30 (±8.54) for males, and 66.09 (±8.16) for females. Man:woman ratio: 43.6%:56.4% in total. Overall prevalence of influenza vaccination was 23.6%, and the pneumococcal vaccination rate was 10.8% among COPD patients. Influenza and pneumococcal vaccination showed a significant protective effect and reduced the occurrence of exacerbations in the following year, influenza vaccination OR: 2.11 (95% CI: 0.88-5.02), pneumococcal vaccination OR: 1.06 (95% CI: 0.84-1.34), when taking both vaccination: OR: 2.37 (95% CI: 1.39-4.08).

Conclusions

We found association between influenza and pneumococcal vaccination and the reduced risk of hospitalization due to exacerbations in the ensuing year. The prevalence of vaccination is significantly below the optimal level.

Chronic Obstructive Pulmonary Disease (COPD) management in the community: how could primary care team contribute?

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive lung disease commonly encountered in primary care. This study aimed to audit COPD care at primary care clinics of Hong Kong and to work out improvement strategies.

METHOD

All COPD patients aged 40 or above who had been followed up at 13 public primary care clinics of Kowloon Central Cluster (KCC) under the Hospital Authority of Hong Kong (HAHK) were included in this clinic audit. Evidence-based audit criteria and performance standards were established after thorough literature review. Phase 1 was from 1st April 2016 to 31st March 2017, with deficiencies of care identified. It was followed by a one-year implementation phase through which a series of improvement strategies were executed. Outcome of the enhancement was reviewed during Phase 2 from 1st April 2018 to 31st March 2019. Chi-square test and student's t test were used to detect statistically significant changes between Phase 1 and Phase 2.

RESULTS

A total of 2358 COPD cases were identified in Phase 1 where 658 of them were smokers. Of those smokers, 332 (50.5%) had been referred to Smoking Counselling and Cessation Service (SCCS) and 289 (43.9%) actually attended it. 991 cases (42%) received Seasonal Influenza Vaccine (SIV) and 938 cases (39.8%) received Pneumococcal Vaccine (PCV). 698 patients (29.6%) had spirometry done before and 423 patients (17.9%) had been admitted to hospital due to acute exacerbation of COPD (AECOPD). With the concerted effort taken during the implementation phase, Phase 2 data showed significant improvement in nearly all criteria. There was a marked increase in the SIV and PCV uptake rate, spirometry performance rate and most importantly, a significant reduction in AECOPD rate leading to hospital admission (13.5%, P = 0.000043). However, the referral rate and attendance rate of SCCS among smokers remained stagnant (P > 0.05).

CONCLUSION

Via a systematic team approach, COPD care at primary care clinics of KCC under HAHK had been significantly improved for most of the audit criteria, which in turn reduced the burden of the healthcare system.

Limits of the social-benefit motive among high-risk patients: a field experiment on influenza vaccination behaviour

Background

Influenza vaccine uptake remains low worldwide, inflicting substantial costs to public health. Messages promoting social welfare have been shown to increase vaccination intentions, and it has been recommended that health professionals communicate the socially beneficial aspects of vaccination. We provide the first test whether this prosocial vaccination hypothesis applies to actual vaccination behaviour of high-risk patients.

Methods

In a field experiment at a tertiary care public hospital in Istanbul, Turkey, we compare the effects of two motivational messages for promoting vaccination. Using a between-subjects single-blind experimental design patients were randomly assigned to frames emphasizing the vaccine’s benefits to self (n = 125) or social benefits (n = 119). Free influenza vaccination was offered to each patient.

Results

Among 222 patients who were not vaccinated for the season prior to the study (72% medically assessed to be at high risk), 42% in the self-benefit frame chose to receive a vaccination compared with 34% in the social-benefits frame, but the difference was not statistically significant (aOR = 1.63, 95% CI 0.90 to 2.95, p = 0.108). Reasons for vaccination focused primarily on self-benefit (67%) rather than social-benefit (5%). Exploratory analysis showed that the effect of messages depended on patient perception of risk group membership (aOR_High / aOR_Low = 5.59, 95% CI 1.30 to 24.05, p = 0.021). In particular, emphasis on self-benefit was more influential among patients who perceived themselves to be in the risk group (aOR = 6.22, 95% CI 1.69 to 22.88, p = 0.006).

Conclusions

In contrast to the literature observing intentions of low-risk populations, we found no evidence that social-benefit motivates actual vaccination behaviour among a high-risk patient population. Instead, those who self-categorize as being in the high risk group are more motivated by the self-benefit message. Our results suggest that a stratified approach can improve coverage: even if an emphasis on social-benefit could be effective among low-risk groups, an emphasis on self-benefit holds more promise for increasing vaccination in medical organizational settings where high-risk groups are prevalent.

Trial registration

ClinicalTrials.gov NCT04230343 Retrospectively registered on the 13th January 2020.

Improving Influenza Vaccination Coverage Among Patients With COPD: A Pilot Project

Background and objective

Guidelines for chronic obstructive pulmonary disease (COPD) advocate regular influenza vaccination, which has been shown to reduce exacerbations. However, influenza vaccination rates remain low. This quality improvement project was initiated to help improve influenza vaccination rates in a tertiary hospital.

Methods

All patients with COPD in the airway program (TAP) in the National University Hospital at the end of 2013 were recruited. The interventions were implemented in 2014; thus, population was stratified into the pre-intervention group and post-intervention group. Those who died in 2014 were excluded. They were (1) patient education posters in the clinics on the need for regular influenza vaccination, (2) direct interventions by physicians, and (3) intervention by the nurses when vaccinations were neglected. Physicians were made aware of previous vaccination rates, vaccination card reminders were placed in the clinics, and a new electronic healthcare record system (EHR) was implemented. The patients were followed up till the end of 2015 or until death. When an influenza vaccination was administered, the patients were asked which of the interventions led to the vaccination. A questionnaire was delivered to the physicians to determine the interventions that led to any change in vaccination prescription practices.

Results

The pre-intervention influenza vaccination rate was low at 47.7%. The post-intervention influenza vaccination rate improved to 80.7% with the multi-pronged approach. Physicians initiated the majority of vaccinations (87.9%), while nurses helped intervene in a further 12.1%. Physicians’ vaccination prescription practices changed as a result of self-awareness of low vaccination rates, vaccination card reminders, and the new EHR. Patient education made minimal impact.

Conclusion

This project demonstrates that with regular audits to track progress and several easy-to-implement interventions, improving influenza vaccination rates is an achievable goal.

Relationship of pneumococcal and influenza vaccination frequency with health literacy in the rural population in Turkey

INTRODUCTION

Vaccines have been shown to prevent illness, disability and death from vaccine-preventable diseases. The purpose of our study was to analyze the influenza and pneumococcal vaccination status of patients, the factors that influence the uptake of influenza/pneumococcal vaccination and the effects of health literacy (HL) on vaccination.

MATERIALS AND METHODS

In this cross-sectional study, demographic characteristics, comorbid diseases and the pneumococcal and influenza vaccination status in previous years were recorded for each patient. The Turkish version of the European Health Literacy Survey Questionnaire (HLS-EU-Q47) was used to assess HL.

RESULTS

A total of 350 patients were enrolled in the study. A total of 6.3% of patients had received both vaccines. 20% of subjects were vaccinated with influenza vaccine and 11.1% of the subjects were vaccinated with pneumococcal vaccine. Overall HL was insufficient for 70.9%, problematic for 20.6%, sufficient for 7.1% and excellent for 14.2% of patients. Patients who had pneumococcal and influenza vaccination had higher disease prevention HL scores (p = 0.013, p = 0.001; respectively).

DISCUSSION

An insufficient HL level was found to be much higher than previous studies. It was observed that an increase in disease prevention HL was associated with a rise in the rate of pneumococcal and influenza vaccination.

Influenza and pneumonia vaccination rates in patients hospitalized with acute respiratory failure

Background and method: Despite their proven effect, the rates of vaccinations are low. The aim of this study was to determine the rates and associated factors of influenza and pneumonia vaccinations in patients who were hospitalized because of acute respiratory failure. Patients hospitalized because of acute hypoxemic or hypercapnic respiratory failure were recruited for this retrospective study. A survey was conducted with 97 patients. Primary diagnoses, ages, reasons of hospitalizations, education status, vaccination rates, information resources, and thoughts about vaccinations were recorded.Results: In total 45 (46%) of the patients were female, and 52 (54%) were male. The mean age was 67 ± 12 years. The primary diagnoses were lung disorders (n = 77, 79%), cardiac disorders (n = 16, 17%), and neuromuscular disorders (n = 5, 4%). In total 72 (74%) patients had chronic obstructive pulmonary disease (COPD) with primary lung disorders. All patients were hospitalized due to acute respiratory failure. The main reason for acute respiratory failure was infection in 40 patients (42%). The overall influenza and pneumococcal vaccination rates were 26% and 15%, respectively; for patients with COPD it was 30% and 17%, respectively. The main providers of information were doctors (42%). Vaccination status was not associated with infections or other reasons of hospitalization, age, sex, educational status, and number of hospital admissions in the previous year. A total of 51 patients (52%) had no belief in the benefits of vaccinations.Conclusion: Vaccination rates were found to be low in patients who were frequently hospitalized. Vaccination status was not related with hospitalization due to infections and history of hospitalization; awareness of vaccinations should be improved both in doctors and patients.

Influenza vaccination prevalence among the elderly and individuals with chronic disease, and factors affecting vaccination uptake

OBJECTIVE

Our aim is to evaluate influenza vaccination rates among the elderly and individuals with underlying chronic disease, and factors that affect vaccination uptake.

METHODS

The study comprised individuals aged 18-65 years with underlying chronic diseases, and individuals aged over 65 years. Literature-based questionnaires prepared by the researcher regarding vaccination were completed through face-to-face interviews by the principal investigator.

RESULTS

A total of 818 participants were included in the study, 257 (31.4%) were males. The mean age of participants was 57.47 ± 14.11 years; 274 (33.5%) were aged 65 years and over. One hundred and three (12.6%) participants stated that they received vaccinations against influenza annually, and 144 (17.6%) stated that they had vaccination against influenza in the 2015/16 or 2016/17 season. Fifty-two (19%) participants aged more than 65 years stated that they received vaccinations against influenza annually, 75 (27.4%) stated that they had vaccination against influenza in the 2015/16 or 2016/17 season. The most commonly determined reasons for not receiving vaccination were not knowing that it was necessary (34%) and believing that vaccination was not necessary because they were healthy (26%). Statistically significantly more participants who gained their knowledge from a physician were vaccinated than those whose knowledge came from other sources (p < 0.05). Participants who considered that they had sufficient information about influenza were vaccinated more frequently, the results were statistically significant (p < 0.05).

CONCLUSION

Informing target risk groups about influenza vaccination by physicians and increasing awareness about influenza may contribute to increasing vaccination rates.

Flu vaccination among older persons: study of knowledge and practices

BACKGROUND

Surveys of older adults' knowledge relative to flu immunization have highlighted its relevance in the improvement of vaccination coverage. The purpose of this study was to estimate the proportion of older persons who have ever been immunized against seasonal flu in the municipality of Vračar (Belgrade, Serbia), assess their knowledge related to flu and flu vaccination, and to determine factors associated with flu immunization.

METHODS

In the period November 2012-January 2013, 480 persons aged above 65 years were recruited at the Community Health Center, of which 354 persons were finally included in the study. Data were collected using a questionnaire. To assess the level of knowledge, correct answers were awarded 1 point. The total knowledge score ranged from 0 to 17 and was divided into three levels: poor (0-4 points), moderate (5-8 points), good (9-13 points), and excellent (14-17 points).

RESULTS

The proportion of ever vaccinated older persons was 47.7%. Of those, one third (29.1%) had been immunized regularly. Most seniors (61.9%) demonstrated good, whereas one third (29.8%) demonstrated excellent level of knowledge. In terms of reasons for non-compliance, the highest proportion of older persons declined vaccination because "they were in good health" (33.5%) and because "they did not believe that vaccine protects from flu" (31.5%). Independent predictors of being ever immunized against seasonal flu were having higher level of education, being more knowledgeable relative to flu vaccination, and taking more medications.

CONCLUSIONS

Our results indicate that health care sector requires well-coordinated promotion campaigns to enhance acceptance of flu vaccination. Organized immunization counseling could provide accurate, evidence-based information in order to transform misbeliefs, prejudice, and negative attitude towards vaccination.

Immunization status in chronic obstructive pulmonary disease: A multicenter study from Turkey

OBJECTIVE:

The purpose of this study is to detect the prevalence and the factors associated with influenza and pneumococcal vaccination and outcomes of vaccination during 2013–2014 season in patients with chronic obstructive pulmonary disease (COPD) in Turkey.

METHODS:

This was a multicenter retrospective cohort study performed in 53 different centers in Turkey.

RESULTS:

During the study period, 4968 patients were included. COPD was staged as GOLD 1-2-3-4 in 9.0%, 42.8%, 35.0%, and 13.2% of the patients, respectively. Influenza vaccination rate in the previous year was 37.9%; and pneumococcus vaccination rate, at least once during in a life time, was 13.3%. Patients with older age, higher level of education, more severe COPD, and comorbidities, ex-smokers, and patients residing in urban areas had higher rates of influenza vaccination. Multivariate logistic regression analysis showed that advanced age, higher education levels, presence of comorbidities, higher COPD stages, and exacerbation rates were associated with both influenza and pneumococcal vaccination. The number of annual physician/outpatient visits and hospitalizations due to COPD exacerbation was 2.73 ± 2.85 and 0.92 ± 1.58 per year, respectively. Patients with older age, lower education levels, more severe COPD, comorbid diseases, and lower body mass index and patients who are male and are residing in rural areas and vaccinated for influenza had significantly higher rates of COPD exacerbation.

CONCLUSIONS:

The rates of influenza and pneumococcal vaccination in COPD patients were quite low, and the number of annual physician/outpatient visits and hospitalizations due to COPD exacerbation was high in Turkey. Advanced age, higher education levels, comorbidities, and higher COPD stages were associated with both influenza and pneumococcal vaccination.

Impact of a homeopathic medication on upper respiratory tract infections in COPD patients: Results of an observational, prospective study (EPOXILO)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a progressive lung disorder in which airflow is obstructed. Viral or bacterial upper respiratory tract infections (URTIs) may lead to exacerbations. Homeopathic medication administration to COPD patients during the influenza-exposure period may help to reduce the frequency of common URTIs.

METHODS

This prospective, observational, multicenter study was carried out in Cantabria, Spain. Patients with COPD were divided into two groups: group 1 received conventional treatment + homeopathic medication (diluted and dynamized extract of duck liver and heart; Boiron) (OG); group 2 received conventional treatment only (CG). The primary endpoint was the number of URTIs between the 4-5 months follow up (mean 4.72 ± 0.96) from basal to last visit. Secondary endpoints included the duration of URTIs, number and duration of COPD exacerbations, use of COPD drugs, changes in quality of life (QoL), compliance, and adverse events (AEs).

RESULTS

219 patients were analyzed (OG = 109, CG = 110). There was a significant reduction in mean number of URTIs during the follow-up period in OG compared to CG (0.514 ± 0.722 vs. 1.037 ± 1.519, respectively; p = 0.014). Logistic regression analysis showed a 3.3-times higher probability of suffering ≥2 URTI episodes in CG (p = 0.003, n = 72). OG patients having ≥1 URTI also had a significant reduction in mean URTI duration per episode (3.57 ± 2.44 days OG vs. 5.22 ± 4.17 days CG; p = 0.012). There was no significant difference in mean number of exacerbations, mean duration of exacerbations, or QoL between OG and CG. There was a greater decrease in proportion of patients using corticosteroids for exacerbations between baseline and visit 2 in OG compared to CG (22.1% vs. 7.5% fewer respectively, p = 0.005). Exacerbator phenotype patients had a significant decrease in number of URTIs (0.54 ± 0.72 vs. 1.31 ± 1.81; p = 0.011), and fewer COPD exacerbations (0.9 ± 1.3 vs. 1.5 ± 1.7; p = 0.037) in OG vs. CG, respectively.

CONCLUSIONS

Homeopathic medication use during the influenza-exposure period may have a beneficial impact at reducing URTIs' number and duration in COPD patients and at reducing the number of COPD exacerbations in patients with the exacerbator phenotype. Further studies are needed to confirm the effects observed in this study.

Influenza vaccination situation in Middle-East and North Africa countries: Report of the 7th MENA Influenza Stakeholders Network (MENA-ISN)

Background

The Middle East and North Africa (MENA) region faces a dual challenge with regard to influenza infection due to severe zoonotic influenza outbreaks episodes and the circulation of Northern Hemisphere human influenza viruses among pilgrims.

Methods

The MENA Influenza Stakeholder Network (MENA-ISN) was set-up with the aim of increasing seasonal influenza vaccination coverage by (i) enhancing evidence-based exchanges, and (ii) increasing awareness on the safety and benefits of seasonal vaccination. During the 7th MENA-ISN meeting, representatives from 8 countries presented their influenza surveillance, vaccination coverage and actions achieved and provided a list of country objectives for the upcoming 3 years.

Results

MENA-ISN countries share the goal to reduce influenza related morbidity and mortality. Participants admitted that lack of knowledge about influenza, its consequences in terms of morbidity, mortality and economy are the major barrier to attaining higher influenza vaccination coverage in their countries. The cost of the vaccine is another key barrier that could contribute to low vaccination coverage. Participants drew a list of strategic interventions to bridge gaps in the knowledge of influenza burden in this region.

Conclusions

Participating countries concluded that despite an increase in vaccine uptake observed during the last few years, influenza vaccination coverage remains relatively low. Priority areas should be identified and action plans tailored to each country situation set-up to investigate the best way to move forward.

A Snapshot of Influenza Surveillance, Vaccine Recommendations, and Vaccine Access, Drivers, and Barriers in Selected Middle Eastern and North African Countries

Objectives

Influenza is a vaccine-preventable acute respiratory viral infection that causes epidemics annually around the globe. A regional influenza stakeholder network (MENA-ISN) comprised of experts assessed the status of influenza prevention and control using a structured survey.

Methods

A survey questionnaire was used to obtain information from each participating country on surveillance system, the burden of disease, influenza vaccination programs, recommendations, funding and access for vaccine and vaccination, target rate, coverage rate monitoring, and drivers and barriers to influenza vaccination.

Results

Out of the 10 countries that participated, nine had an influenza surveillance system and vaccination policy, and seven had World Health Organization (WHO) accredited reference laboratory. Three countries had burden of disease data available and eight had a reimbursement vaccine policy. Influenza vaccine was available in five countries through the Ministry of Health whereas in others, pharmacies also dispensed for the private sector. In all countries, prescribers were physicians, and vaccinators, which could be physicians, nurses, and pharmacists. Eight countries had a set vaccination target rate and only three monitored the influenza coverage rates. Drivers and barriers of vaccination were similar in all countries.

Conclusions

Despite existing policies, influenza vaccination coverage remains far below the WHO recommendations. Increased awareness and effective implementation of policies with collaboration of stakeholders can help increase the rates to reach WHO targets.

Influenza surveillance in Western Turkey in the era of quadrivalent vaccines: A 2003-2016 retrospective analysis

Human influenza is predominantly caused by influenza A virus (IAV) - A/H1N1 and/or A/H3N2 - and influenza B virus (IBV) - B/Victoria and/or B/Yamagata, which co-circulate each season. Influenza surveillance provides important information on seasonal disease burden and circulation, and vaccine content for the following season. To study the circulating influenza subtypes/lineages in western Turkey. Community-based sentinel surveillance results during 2003-2016 (weeks 40-20 each season; but week 21, 2009 through week 20, 2010 during the pandemic) were analyzed. Nasal/nasopharyngeal swabs from patients with influenza-like illness were tested for influenza virus and characterized as A/H1N1, A/H3N2, or IBV. A subset of IBV samples was further characterized as B/Victoria or B/Yamagata. Among 14,429 specimens (9,766 collected during interpandemic influenza seasons; 4,663 during the 2009-2010 pandemic), 3,927 (27.2%) were positive. Excluding the pandemic year (2009-2010), 645 (27.4%) samples were characterized as A/H1N1 or A/H1N1/pdm09, 958 (40.7%) as A/H3N2, and 752 (31.9%) as IBV, but the dominant subtype/lineage varied widely each season. During the pandemic year (2009-2010), 98.3% of cases were A/H1N1/pdm09. IBV accounted for 0-60.2% of positive samples each season. The IBV lineages in circulation matched the vaccine IBV lineage >50% in six seasons and <50% in four seasons; with an overall mismatch of 49.7%. IBV cases tended to peak later than IAV cases within seasons. These results have important implications for vaccine composition and optimal vaccination timing. Quadrivalent vaccines containing both IBV lineages can reduce B-lineage mismatch, thus reducing the burden of IBV disease.

Seasonal Influenza Vaccine Effectiveness in Preventing Laboratory Confirmed Influenza in 2014-2015 Season in Turkey: A Test-Negative Case Control Study

BACKGROUND

Influenza has an important public health impact worldwide with its considerable annual morbidity among persons with or without risk factors and its serious complications among persons in high-risk groups. The seasonal influenza vaccine is essential for preventing the burden of influenza in a population. Since the vaccine is reformulated each season according to the virus serotypes in circulation, its effectiveness can vary from season to season. Vaccine effectiveness is defined as the relative risk reduction in vaccinated individuals in observational studies.

AIMS

To calculate influenza vaccine effectiveness in preventing laboratory-confirmed influenza in the Turkish population for the first time using the national sentinel surveillance data in the 2014-2015 influenza season.

STUDY DESIGN

Test-negative case-control study.

METHODS

We compared vaccination odds of influenza positive cases to influenza negative controls in the national influenza surveillance in Turkey to estimate influenza vaccine effectiveness.

RESULTS

The influenza vaccine effectiveness against influenza A (H1N1) (68.4%, 95% CI: -2.9 to 90.3) and B (44.6%, 95% CI: -27.9 to 66.6) were moderate, and the influenza vaccine effectiveness against influenza A (H3N2) (75.0%, 95% CI: -86.1 to 96.7) was relatively high; all had low precision given the low vaccination coverage. Overall, the influenza vaccination coverage rate was 4.2% (95% CI: 3.5 to 5.0), which is not sufficient to control the burden of influenza.

CONCLUSION

In Turkey, national surveillance for influenza should be strengthened and utilised annually for the assessment of influenza vaccine effectiveness with more precision. Annual influenza vaccine effectiveness in Turkey should continue to be monitored as part of the national sentinel influenza surveillance.

Individual background factors associated with vaccination for seasonal influenza in Japanese schoolchildren

There is little evidence about how individual background factors affect seasonal influenza vaccination of children. At the end of the 2014/2015 influenza season, a cross-sectional questionnaire survey of all elementary schoolchildren in 29 schools in Matsumoto City, Japan, was conducted to obtain information about vaccine uptake activity and individual background factors. Of the 10,524 subjects who responded, 5063 (48.1%) had been vaccinated. Grade in school, underlying disease, number of siblings, and diagnosis with and vaccination for influenza during the previous influenza season differed significantly in vaccinated and unvaccinated groups. Multivariate logistic regression showed that underlying disease and vaccination during the previous influenza season was associated with a higher rate of vaccination, whereas higher grade in school and having ≥3 siblings was associated with a lower rate of vaccination. The findings may be useful to promote a vaccination policy recommending financial support to households with many children or to encourage higher uptake of vaccination in higher grade children.

Better knowledge and regular vaccination practices correlate well with higher seasonal influenza vaccine uptake in people at risk: Promising survey results from a university outpatient clinic

BACKGROUND

The knowledge, beliefs, opinions, and attitudes of patients and their relatives regarding seasonal influenza vaccination were evaluated.

METHODS

This descriptive study was undertaken in the outpatient clinics of Baskent University Hospital. There were 566 responders who completed a self-administered questionnaire.

RESULTS

The mean age of participants was 48.35 years, and 16.8% were ≥65 years. Of the responders, 21.7% were vaccinated this year, whereas 57.8% did not desire to get it. Vaccination rates were significantly higher among responders ≥65 years of age (56.4%), those having at least 1 chronic illness (46.5%), and those who were vaccinated regularly every year (22.2%). Half of the responders did not know that the vaccine was reimbursed for people at risk. The most common reason for refusing the influenza vaccine was not getting the flu frequently (51.2%). Fear of side effects, concerns about vaccine's effectiveness, and belief that vaccine causes the flu were other common reasons for not being vaccinated. Of the responders, 77% believed that getting official information or a recommendation from a physician would influence their decision about seasonal influenza vaccination.

CONCLUSIONS

People who are at risk or vaccinated regularly display a higher vaccine uptake and better knowledge of influenza and vaccination. The opinions and attitudes of this study population may assist in developing strategies for changing attitudes of the public toward influenza vaccination.

Influenza and Pneumonia Vaccination Rates and Factors Affecting Vaccination among Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

Influenza and pneumococcal vaccinations are recommended in chronic obstructive pulmonary disease patients to decrease associated risks at all stages. Although the prevalence of chronic obstructive pulmonary disease is high in our country, as previously reported, vaccination rates are low.

AIMS

To assess the vaccination rates of chronic obstructive pulmonary disease patients and factors that may affect these.

STUDY DESIGN

Multi-centre cross-sectional study.

METHODS

Patients admitted to the chest diseases clinics of six different centres between 1 February 2013 and 1 January 2014 with a pre-diagnosis of Chronic obstructive pulmonary disease according to the Global initiative for chronic obstructive lung disease criteria, who were in a stable condition were included in the study. The survey, which included demographic characteristics, socio-economic status, severity of disease and vaccination information, was first tested on a small patient population before the study. The survey was completed by the investigators after obtaining written informed consent.

RESULTS

The average age of the 296 included patients was 66.3±9.3 years and 91.9% were male. Of these, 36.5% had the influenza vaccination and 14.1% had the pneumococcal vaccination. The most common reason for not being vaccinated was 'no recommendation by doctors': 57.2% in the case of influenza vaccinations, and 46.8% in the case of pneumococcal vaccinations. Both vaccination rates were significantly higher in those patients with comorbidities (influenza vaccination p<0.001; pneumococcal vaccination p=0.06). There was no significant correlation with age, gender, smoking and severity of disease (p>0.05). Vaccination rates were significantly higher in those with a white-collar occupation and higher education level, and who presented to a university hospital (p<0.001).

CONCLUSION

Medical professionals do not request vaccinations as often as the International Guidelines suggest for chronic obstructive pulmonary disease patients. Awareness of the importance of these vaccinations among both doctors and patients needs to be addressed.

Cost-Effectiveness of Increasing Influenza Vaccination Coverage in Adults with Type 2 Diabetes in Turkey

Objective

In Turkey, the prevalence of diabetes is high but the influenza vaccination coverage rate (VCR) is low (9.1% in 2014), despite vaccination being recommended and reimbursed. This study evaluated the cost-effectiveness of increasing the influenza VCR of adults with type 2 diabetes in Turkey to 20%.

Methods

A decision-analytic model was adapted to Turkey using data derived from published sources. Direct medical costs and indirect costs due to productivity loss were included in the societal perspective. The time horizon was set at 1 year to reflect the seasonality of influenza.

Results

Increasing the VCR for adults with type 2 diabetes to 20% is predicted to avert an additional 19,777 influenza cases, 2376 hospitalizations, and 236 deaths. Associated influenza costs avoided were estimated at more than 8.3 million Turkish Lira (TRY), while the cost of vaccination would be more than TRY 8.4 million. The incremental cost-effectiveness ratio was estimated at TRY 64/quality-adjusted life years, which is below the per capita gross domestic product of TRY 21,511 and therefore very cost-effective according to World Health Organization guidelines. Factors most influencing the incremental cost-effectiveness ratio were the excess hospitalization rate, inpatient cost, vaccine effectiveness against hospitalization, and influenza attack rate. Increasing the VCR to >20% was also estimated to be very cost-effective.

Conclusions

Increasing the VCR for adults with type 2 diabetes in Turkey to ≥20% would be very cost-effective.

Factors effecting influenza vaccination uptake among health care workers: a multi-center cross-sectional study

BACKGROUND

The present study aimed to identify factors affecting vaccination against influenza among health professionals.

METHODS

We used a multi-centre cross-sectional design to conduct an online self-administered questionnaire with physicians and nurses at state and foundation university hospitals in the south-east of Turkey, between 1 January 2015 and 1 February 2015. The five participating hospitals provided staff email address lists filtered for physicians and nurses. The questionnaire comprised multiple choice questions covering demographic data, knowledge sources, and Likert-type items on factors affecting vaccination against influenza. The target response rate was 20 %.

RESULTS

In total, 642 (22 %) of 2870 health professionals (1220 physicians and 1650 nurses) responded to the questionnaire. Participants' mean age was 29.6 ± 9.2 years (range 17-62 years); 177 (28.2 %) were physicians and 448 (71.3 %) were nurses. The rate of regular vaccination was 9.2 % (15.2 % for physicians and 8.2 % for nurses). Increasing age, longer work duration in health services, being male, being a physician, working in an internal medicine department, having a chronic disease, and living with a person over 65 years old significantly increased vaccination compliance (p < 0.05). We found differences between vaccine compliant and non-compliant groups for expected benefit from vaccination, social influences, and personal efficacy (p < 0.05). Univariate analysis showed differences between the groups in perceptions of personal risks, side effects, and efficacy of the vaccine (p < 0.05). Multivariate analysis found that important factors influencing vaccination behavior were work place, colleagues' opinions, having a chronic disease, belief that vaccination was effective, and belief that flu can be prevented by natural ways.

CONCLUSION

Numerous factors influence health professionals' decisions about influenza vaccination. Strategies to increase the ratio of vaccination among physicians and nurses should consider all of these factors to increase the likelihood of success.

Striking Similarities in the Presentation and Duration of Illness of Influenza A and B in the Community: A Study Based on Sentinel Surveillance Networks in France and Turkey, 2010-2012

Influenza B represents a high proportion of influenza cases in some seasons (even over 50%). The Influenza B study in General Practice (IBGP) is a multicenter study providing information about the clinical, demographic and socio-economic characteristics of patients affected by lab-confirmed influenza A or B. Influenza B patients and age-matched influenza A patients were recruited within the sentinel surveillance networks of France and Turkey in 2010–11 and 2011–12 seasons. Data were collected for each patient at the swab test day, after 9±2 days and, if not recovered, after 28±5 days. It was related to patient's characteristics, symptoms at presentation, vaccination status, prescriptions of antibiotics and antivirals, duration of illness, follow-up consultations in general practice or emergency room. We performed descriptive analyses and developed a multiple regression model to investigate the effect of patients and disease characteristics on the duration of illness. Overall, 774 influenza cases were included in the study: 419 influenza B cases (209 in France and 210 in Turkey) and 355 influenza A cases (205 in France and 150 in Turkey). There were no differences between influenza A and B patients in terms of clinical presentation and number of consultations with a practitioner; however, the use of antivirals was higher among influenza B patients in both countries. The average (median) reported duration of illness in the age groups 0–14 years, 15–64 years and 65+ years was 7.4 (6), 8.7 (8) and 10.5 (9) days in France, and 6.3 (6), 8.2 (7) and 9.2 (6) days in Turkey; it increased with age but did not differ by virus type; increased duration of illness was associated with antibiotics prescription. In conclusion, our findings show that influenza B infection appears not to be milder disease than influenza A infection.

Factors associated to vaccination against influenza among elderly in a large Brazilian metropolis

BACKGROUND

This study aimed to estimate coverage and identify factors associated to vaccination against influenza in the elderly population.

METHODS

The study design was cross-sectional and population based. Data was collected in 2010 by the Health, Well-Being and Aging Study. Sample consisted of 1,341 community-dwelling elderly, in São Paulo, Brazil. Association between vaccination and covariates was evaluated by means of prevalence ratios estimated by Poisson regression models.

RESULTS

Self-reported vaccination coverage was 74.2% (95% confidence interval: 71.3-76.9). Remaining physically active and having had recent interaction with health services, mainly with public units of healthcare, were the main incentives to increase vaccination coverage among the elderly; whereas lower age, living alone and absent interaction with health services were the main constraints to influenza vaccination at the community level. These covariates had already been reported to influence influenza vaccination of elders in previous years.

CONCLUSION

Previous knowledge already available on the main constraints to influenza vaccination has not allowed to remove them. Influenza campaigns should be strengthened to increase vaccination coverage, especially in the group more reticent to vaccination. Instructing healthcare providers to recommend vaccine uptake is an important piece of this puzzle.

Attitudes, Intentions, and Barriers Toward Influenza Vaccination Among Pregnant Korean Women

Following our study of attitudes, barriers, and intentions concerning the influenza vaccination among pregnant women in South Korea, we discovered that women displaying a more positive attitude toward the influenza vaccination were more likely to receive it during their pregnancy. We also found that attitudes toward vaccination were more positive among vaccinated pregnant women than among those who were unvaccinated. Furthermore, women showed a greater intention to get vaccinated if a clinician, rather than friends, recommended it. The major perceived barriers to receiving an influenza vaccination were being pregnant, fearing harm to the baby, feeling healthy, and thinking it is unnecessary.

Low seroprevalence of diphtheria, tetanus and pertussis in ambulatory adult patients: the need for lifelong vaccination

BACKGROUND

Tetanus, diphtheria, pertussis and measles are vaccine preventable diseases that have been reported to cause morbidity and mortality in adult population in the recent years. We aimed to document the seropositivity rates and vaccination indication for these four vaccine preventable diseases among adult and elderly patients who were seen as outpatients in a university hospital.

METHODS

Blood samples for tetanus, diphtheria, pertussis and measles antibodies were obtained. Results were evaluated with regards to protection levels and booster vaccine indications according to the cut-off values.

RESULTS

A total of 1367 patients consented for the study and 1303 blood samples were available for analysis at the end of the study. The antibody levels against measles conferred protection in 98% of patients. However, 65% of the patients had no protection for diphtheria, 69% had no protection for tetanus and 90% of the patients had no protection for pertussis. Only 1.3% of the study population had seropositivity against three of the diseases-Tdap booster was indicated in 98.7%. Multivariable logistic regression showed that tetanus protection decreased with increasing age. Having a chronic disease was associated with a lower rate of protective antibodies for pertussis.

CONCLUSIONS

We demonstrated very low rates of protection against three of the vaccine preventable diseases of childhood-diphtheria, pertussis and tetanus. Booster vaccinations are required in adult life in accordance with national and international adult vaccination guidelines. The concept of "lifelong vaccination" should be implemented and every encounter with the patient should be regarded as a chance for catch-up.

Budget constraint and vaccine dosing: a mathematical modelling exercise

BACKGROUND

Increasing the number of vaccine doses may potentially improve overall efficacy. Decision-makers need information about choosing the most efficient dose schedule to maximise the total health gain of a population when operating under a constrained budget. The objective of this study is to identify the most efficient vaccine dosing schedule within a fixed vaccination budget from a healthcare payer perspective.

METHODS

An optimisation model is developed in which maximizing the disease reduction is the functional objective and the constraint is the vaccination budget. The model allows variation in vaccination dosing numbers, in cost difference per dose, in vaccine coverage rate, and in vaccine efficacy. We apply the model using the monovalent rotavirus vaccine as an example.

RESULTS

With a fixed budget, a 2-dose schedule for vaccination against rotavirus infection with the monovalent vaccine results in a larger reduction in disease episodes than a 3-dose scheme with the same vaccine under most circumstances. A 3-dose schedule would only be better under certain conditions: a cost reduction of >26% per dose, combined with vaccine efficacy improvement of ≥5% and a target coverage rate of 75%. Substantial interaction is observed between cost reduction per dose, vaccine coverage rate, and increased vaccine efficacy. Sensitivity analysis shows that the conditions required for a 3-dose strategy to be better than a 2-dose strategy may seldom occur when the budget is fixed. The model does not consider vaccine herd effect, precise timing for additional doses, or the effect of natural immunity development.

CONCLUSIONS

Under budget constraint, optimisation modelling is a helpful tool for a decision-maker selecting the most efficient vaccination dosing schedule. The low dosing scheme could be the optimal option to consider under the many scenarios tested. The model can be applied under many different circumstances of changing dosing schemes with single or multiple vaccines.

Influenza vaccination uptake among the working age population of Japan: results from a national cross-sectional survey

Background

Influenza vaccination rates among Japanese people of working age (20–69 years) is currently suboptimal, and the reasons for this have not been clearly elucidated. This study examined factors associated with vaccination intention among the working age population in Japan during September 2011, one-month prior to influenza vaccination becoming available.

Methodology/Principal Findings

A web-based survey of intention to be vaccinated against influenza in the coming season was undertaken among 3,129 Japanese aged 20 to 69 years. Multinomial logistic regression analysis was used to explore the associations between vaccination intent and other variables. Influenza vaccination intent was associated with having been vaccinated in the previous year (Odds Ratio (OR): 3.81; 95% Confidence Interval (CI): 3.75–3.86), the number of children per household (one compared with zero; OR: 1.37; 95%CI: 1.11–1.65), and household income ($50,000 to <$100,000 compared with $0 to <$50,000; OR: 1.30; 95%CI: 1.07–1.54). Smoking was inversely associated with influenza vaccine uptake (current smokers compared with non-smokers; OR: 0.79; 95%CI: 0.61–0.98). A history of either the survey respondent or a household member having being medically diagnosed with influenza in the previous year was not statistically associated with future influenza vaccination intent.

Conclusions/Significance

Overall, this suggests that intention to be vaccinated among working age Japanese is associated with a past history of influenza vaccination, having children, and the household's income. As such, consideration of these factors should now form the cornerstone of strategies to encourage increased uptake of vaccination against influenza in future years.