Innovations in adult influenza vaccination in China, 2014-2015: Leveraging a chronic disease management system in a community-based intervention

The impact of the COVID-19 pandemic and the free vaccination policy on seasonal influenza vaccination uptake among older adults in Ningbo, Eastern China

In 2020-21, during the COVID-19 pandemic, a free influenza vaccination program was initiated among the elderly residents in Ningbo, China. The impact of the COVID-19 pandemic and free vaccination policy on influenza vaccine uptake needs to be evaluated. The influenza vaccine uptake among individuals born before 31 December, 1962 from 2017-18 to 2022-23 season in Ningbo was analyzed. Multivariate logistic regressions were used to estimate the impact of the COVID-19 pandemic and free vaccination policy. Our analysis included an average of 1,856,565 individuals each year. Influenza vaccination coverage increased from 1.14% in 2017-18 to 33.41% in 2022-23. The vaccination coverage among the free policy target population was 50.03% in 2022-23. Multivariate analysis showed that free vaccination policy increased influenza vaccine uptake most (OR = 11.99, 95%CI: 11.87-12.11). The initial phase of the pandemic was associated with a positive effect on influenza vaccination (OR = 2.09, 95%CI: 2.07-2.12), but followed by a negative effect in the subsequent two seasons(2021-22: OR = 0.75, 95%CI: 0.73-0.76; 2022-23: OR = 0.40, 95%CI: 0.39-0.40). COVID-19 vaccination in the current season was a positive predictor of influenza vaccine uptake while not completing booster COVID-19 vaccination before was negative predictor in 2022-23. Having influenza vaccine history and having ILI medical history during the last season were also positive predictors of influenza vaccine uptake. Free vaccination policies have enhanced influenza vaccination coverage among elderly population. The COVID-19 pandemic plays different roles in different seasons. Our study highlights the need for how to implement free vaccination policies targeting vulnerable groups with low vaccination coverage.

Increasing Influenza Vaccination Rates among Patients with Type 2 Diabetes Mellitus in Chongqing, China: A Cross-Sectional Analysis Using Behavioral and Social Drivers Tools

BACKGROUND

Influenza vaccination is essential for type 2 diabetes mellitus (T2DM) patients due to their higher risks of severe complications and mortality from influenza. This study investigated the willingness of T2DM patients in Chongqing, China, to receive the influenza vaccination during the 2023/2024 season, using behavioral and social drivers (BeSD) tools to improve vaccination uptake in this high-risk group.

METHODS

A multi-stage sampling method was used to select participants, and face-to-face surveys were conducted in community health centers between March 1 and May 1, 2023. Binary logistic regression was used to analyze the factors influencing vaccination willingness, and standardized scores identified barriers and drivers.

RESULTS

Among 1672 T2DM patients, 11.7% had been vaccinated during the 2022/2023 season, and 59.6% were willing to receive the vaccination in the 2023/2024 season. Higher willingness was associated with ethnic minorities (odds ratio [OR], 3.18, 95% confidence interval [CI]: 1.58-6.39), being unemployed individuals (OR 2.69, 95% CI: 1.60-4.52), higher monthly household income per capita (OR 2.72, 95% CI: 1.65-4.50), having diabetes complications (OR 1.76, 95% CI: 1.23-2.51), sufficient vaccine knowledge (OR 1.87, 95% CI: 1.48-2.37), and previous vaccination (OR 7.75, 95% CI: 4.83-12.44). Concerning BeSDs, fear of infecting friends or family members and trust in vaccine efficacy were the predominant drivers, while high vaccine costs were the greatest barrier.

CONCLUSIONS

Future strategies should focus on improving vaccine knowledge, supporting healthcare workers and peer recommendations, and enhancing vaccination policies. Key interventions such as health education among high-risk groups, such as unemployed individuals, advocacy campaigns, pay-it-forward strategies, and policies for free vaccination could improve coverage in Chongqing.

Effectiveness of educational interventions for healthcare workers on vaccination dialogue with older adults: a systematic review

BACKGROUND

Healthcare workers (HCW) significantly influence older adults' vaccine acceptance. This systematic review aimed to identify effective educational interventions for HCWs that could enhance their ability to engage in a dialogue with older adults on vaccination.

METHODS

Medline, Scopus, Cochrane library and grey literature were searched for comparative studies investigating educational interventions concerning older adult vaccinations. The search encompassed all languages and publication years. Analysis was performed on the outcomes 'vaccines offered or ordered' and 'vaccination rates'. Whenever feasible, a sub-analysis on publication year was conducted. Methodological limitations were assessed using the RoB 2 for RCTs and the GRADE checklist for non-randomized studies. Study outcomes were categorized according to the four-level Kirkpatrick model (1996) for effectiveness: reaction, learning, behaviour, and results.

RESULTS

In total, 48 studies met all inclusion criteria. Most studies included reminder systems signalling HCWs on patients due for vaccination. Other interventions included seminars, academic detailing and peer-comparison feedback. Four articles reporting on the reaction-level indicated that most HCWs had a favourable view of the intervention. Two of the six articles reporting on the learning-level observed positive changes in attitude or knowledge due to the intervention. Seventeen studies reported on the behaviour-level. An analysis on eleven out of seventeen studies focusing on vaccines 'ordered' or 'offered' outcomes suggested that tailored reminders, particularly those implemented before 2000, were the most effective. Out of 34 studies reporting on the result-level, 24 were eligible for analysis on the outcome 'vaccination rate', which showed that compared to usual care, multicomponent interventions were the most effective, followed by tailored reminders, especially those predating 2000. Nonetheless, tailored reminders often fell short compared to other interventions like standing orders or patient reminders. In both the behaviour-level and result-level 'education only' interventions frequently underperformed relative to other interventions. Seventeen out of the 27 RCTs, and seven of the 21 non-randomized studies presented a low-to-medium risk for bias in the studies' findings.

CONCLUSIONS

Tailored reminders and multicomponent interventions effectively assist HCWs in addressing vaccines with older adults. However, education-only interventions appear to be less effective compared to other interventions rates, attitude, knowledge.

Assessing interventions to encourage primary care health workers to recommend influenza vaccination and the impact on vaccination uptake for persons with Non-Communicable diseases in China

BACKGROUND

Influenza vaccination coverage is low among persons with non-communicable diseases (NCDs) in China. Chinese health workers (HWs) do not routinely recommend influenza vaccination despite evidence that recommendations increase vaccine uptake. This study aims to assess whether interventions increased primary care HWs' recommendation for influenza vaccination and measure their impact on influenza vaccine uptake in persons with NCDs.

METHODS

We conducted a cluster randomized controlled study in public primary healthcare clinics in Hubei from November 2018 through April 2019. In the intervention clinics, primary care HWs received training on the benefits of influenza vaccination and were asked to recommend influenza vaccine in routine primary healthcare for persons with NCDs. In the control clinics, primary care HWs did not receive training and provided standard services. We conducted questionnaire surveys before and after the intervention to collect information about recommendations made and receipt of influenza vaccines.

RESULTS

A total of 896 primary care HWs and 4552 persons with NCDs were included. After intervention, a higher percentage of HWs recommended influenza vaccines in intervention clinics compared to control clinics. Vaccinated primary care HWs were more likely to recommend vaccination. Persons with NCDs reported higher influenza vaccination coverage in intervention than control clinics, and primary care HWs' recommendation increased vaccination uptake among persons with NCDs.

CONCLUSIONS

Vaccinated primary care HWs were more likely to recommend influenza vaccination than unvaccinated HWs. Promoting primary care HWs' vaccination and encouraging them to recommend influenza vaccination during routine primary healthcare could increase influenza vaccine receipt among persons with NCDs. Registration number ChiCTR2200067140.

A review of factors influencing vaccination policies and programs for older adults globally

Policies and programs to increase vaccine coverage rates among adults 50 years of age or older are limited and vaccine uptake is often suboptimal. Our review evaluated evidence on the effectiveness and success of adult-targeted vaccination interventions and identified literature gaps. Literature was retrieved (2021) from PubMed, Embase, and Google Scholar databases. Outcomes assessed included data on an intervention's effectiveness and impact on vaccine uptake. Interventions were characterized thematically: affordability (n = 9), awareness (n = 25), and vaccination access (n = 6); and included influenza, pneumococcal, tetanus-containing, and herpes zoster vaccines. Interactive interventions directed toward patients, including provider-led educational initiatives and provider recommendations showed more positive associations than less interactive interventions, such as posters and reminder-recall letters. Provider interventions, including awareness campaigns, incentives, affordability efforts, or vaccination site expansion generally showed positive associations. Combining interventions was found to be successful across several studies. Barriers and interventions varied for population subgroups, therefore, tailoring programs is critical.

Cluster randomized trial of influenza vaccination in patients with acute heart failure in China: A mixed-methods feasibility study

Uncertainties about the efficacy of influenza vaccination for populations with heart failure (HF) in preventing cardiovascular outcomes, as well as lack of effective vaccination strategies, may contribute to low vaccine coverage rate (VCR) in China and globally. We assessed the feasibility of a strategy to promote influenza vaccines in patients hospitalized with acute HF in China and to inform the design of a hybrid effectiveness-implementation cluster randomized trial to evaluate this strategy on mortality and hospital re-admission. We conducted a cluster randomized pilot trial involving 11 hospitals in Henan Province in China, with mixed-methods evaluation between December 2020 and April 2021. A process evaluation involved interviews with 51 key informants (patients, health professionals, policy makers). The intervention included education about influenza vaccination and availability of free vaccines administered prior to hospital discharge for HF patients, while usual care included attending community-based points of vaccination (PoV) for screening and vaccination. Implementation outcomes focused on reach, fidelity, adoption, and acceptability. Recruitment rates were assessed for trial feasibility. Effectiveness outcomes were influenza VCR, HF-specific rehospitalizations and mortality at 90 days. A total of 518 HF patients were recruited from 7 intervention and 4 usual care hospitals (mean of 45 participants per hospital per month). VCR was 89.9% (311/346, 86.1-92.8%) in the intervention group and 0.6% (1/172, 0.0-3.7%) in the control group. The process evaluation demonstrated reach to patients with lower socioeconomic and education status. There was good fidelity of the intervention components, with education and PoV set up processes being adapted to local hospital workflow and workforce capacity. Intervention was acceptable and adopted by patients and health professionals. However, outside of a trial setting, concerns were raised around vaccination reimbursement costs, workforce accountability and capacity. The intervention strategy appears feasible and acceptable for improving VCR in HF patients at county-level hospitals in China. Trial registration: This pilot trial is registered with the acronym PANDA II Pilot (Population Assessment of Influenza and Disease Activity) at ChiCTR.org.cn (ChiCTR2000039081).

A survey of systemic lupus erythematosus patients' attitudes toward influenza and pneumococcal vaccination in Southwest China

Introduction

Vaccination is the most effective measure for prevention against infectious diseases in patients with systemic lupus erythematosus (SLE). Therefore, it is important to know SLE patients' attitudes toward influenza and pneumococcal vaccination. This study aimed to investigate the attitude toward influenza and pneumococcal vaccination among SLE patients in Southwest China and its influencing factors.

Methods

A web-based questionnaire was conducted to collect data regarding SLE patients' demographics, history of infections, medications, comorbidities, attitudes toward infection and vaccination, rates of influenza and pneumococcal vaccination, and role of health professionals in promoting vaccination. Univariate and multivariate logistic regression analyses were conducted to assess the vaccination willingness-associated factors.

Results

A total of 251 patients participated in the survey and 240 questionnaires were completed and statistically analyzed. The influenza and pneumococcal vaccination rates were 8.3 and 1.7%, respectively. The top three reasons for non-vaccination were worrying about the SLE exacerbation or flare resulting from the vaccine or its adjuvants, being concerned about adverse events, and the lack of awareness of vaccine availability. More than half of the participants were willing to be vaccinated against influenza (56.2%) and pneumococcus (52.9%). Factors associated to the willingness to receive the influenza vaccine and pneumococcal vaccine were being afraid of infection, believing in the efficacy of influenza vaccination, lower family income, less perceived care from family members, perceived susceptibility to pneumococcal infection, and perceiving influenza and pneumococcal vaccination as beneficial for health.

Conclusions

The influenza and pneumococcal vaccination rates are low among SLE patients in Southwest China. The positive perspective of vaccination on health represented the most impacting factor on their willingness to undergo influenza and pneumococcal vaccination. Non-vaccinated patients were mainly concerned about exacerbation of the disease or adverse events caused by vaccines. It is important to improve the compliance with the guideline-recommended roles of health professionals and to promote the collaboration between rheumatology and primary care teams.

Factors associated with influenza vaccination coverage and willingness in the elderly with chronic diseases in Shenzhen, China

Elderly individuals with chronic illnesses are more prone to get influenza. We aimed to investigate the factors associated with influenza coverage and willingness in chronic disease patients aged ≥60 years in Longhua district, Shenzhen City of southern China. Data collected in October 2020 were used in this work. The immunization status of older persons with chronic conditions and their willingness to receive the vaccine were assessed. Multivariable logistic regression was employed to determine the respective independent factors related to vaccination coverage and willingness for influenza. Only 4.8% of 5045 people were immunized against influenza, whereas 92.7% of the individuals agreed to receive the vaccine. Individuals between the ages of 70 and 79 (adjusted OR [aOR] 1.47, P = .012), those with higher education levels (aOR 1.53, P = .005 for high school; aOR 2.44, P < .001 for college or above), those who use of a family doctor (aOR 2.91, P < .001), those who frequently have physical examinations once a year (aOR 2.52, P < .001), and those who have never smoked (aOR 1.62, P = .018) were positively associated with the influenza vaccination. Meanwhile, older age was adversely linked with influenza vaccination willingness (aOR 0.68 for 70-79 years, P = .003; aOR 0.55 for≥80 years, P = .025) in contrast to those aged 60-69. High willingness to get vaccinated was more frequent in people with a high school diploma (aOR 1.33, P = .037). In this work, we observed that the coverage is poor but the immunization desire is high regarding influenza vaccination. Interestingly, older age was associated with higher coverage and lower willingness. These suggest that raising immunization rates among older people with chronic conditions and strengthening health education for caregivers should be the primary concerns.

The Vaccine Hesitancy Profiles and Determinants of Seasonal Influenza among Chinese Community Healthcare Workers: A Cross-Sectional Study

This paper is an evaluation of seasonal influenza vaccination hesitancy (IVH) and its determinants among community HCWs in Chongqing, a city in southwest China. Methods: A cross-sectional survey of 1030 community HCWs with direct or indirect patient contact was conducted from July to September 2021 using a self-administered electronic questionnaire. Possible factors for IVH among community HCWs were investigated by multivariable logistic regression to yield adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Results: Overall, 46.2% of community HCWs were vaccinated in the 2020–2021 season, while 65.8% of community HCWs had IVH. “Don’t know the coverage in China” (OR: 1.46, 95% CI: 1.01–2.11; 40-year-old group OR: 3.02, 95% CI: 1.92–4.76), “complacency” (OR: 4.55, 95% CI: 3.14–6.60) were positively related with having IVH. The community HCWs that had a history of influenza vaccination (OR: 0.67 95% CI: 0.48–0.95) and groups with confidence and convenience (OR: 0.08, 95% CI: 0.06–0.12; OR: 0.34, 95% CI: 0.23–0.52, respectively) were more likely to completely accept vaccination. Conclusions: Measures such as improving the awareness and knowledge of influenza and vaccination and expanding the free vaccination policy, combined with improving the convenience of the vaccination service, will promote increased seasonal influenza vaccination-coverage in community HCWs in Chongqing.

Impact of video-led educational intervention on uptake of influenza vaccine among the elderly in western China: a community-based randomized controlled trial

BACKGROUND

Influenza vaccination coverage rate among the elderly is low in China. We aimed to evaluate the impact of video-led educational intervention on influenza vaccine uptake among the Chinese elderly.

METHODS

A randomized controlled trial was conducted in 8 communities of Xi'an, a representative city in western China. Elderly aged over 60 years were randomized to the control group and intervention group (12-minute video education on influenza and its vaccination). Participants' knowledge, attitudes, and practices (KAP) of influenza was assessed by using a questionnaire survey before and after the intervention. The primary outcomes were participants' willingness to get influenza vaccinated and their actual uptake rates in the 2020-21 flu season. Secondary outcomes were the variations of pre- and post-intervention KAP scores. Intention-to-treat analysis was performed to analyze the data, and sensitivity analyses were conducted to examine the robustness of the results.

RESULTS

A total of 350 people were enrolled, with 175 individuals for each group. Participants in the intervention group were more willing to receive influenza vaccination than those in the control group (64.6% vs. 51.4%, p<0.05). The influenza vaccination uptake rate occurred in 10.3% of participants in the intervention group and 3.4% in the control group (odds ratio, 3.23; 95% CI 1.25-8.32, p<0.001). The post-intervention KAP scores in the intervention group were significantly higher compared to those in the control group (p<0.001).

CONCLUSION

Video-led education was an effective and feasible approach to improve old people's willingness and uptake of influenza vaccination in western China.

Pharmacists’ Seasonal Influenza Vaccine Recommendations

Seasonal influenza vaccination rates among European countries remain low despite the World Health Organization’s recommendations to vaccinate high-risk groups. Healthcare worker recommendations are strong predictors of increased vaccination uptake in the population. Therefore, this study aimed to analyze seasonal influenza vaccination recommendation behavior among pharmacists towards high-risk groups including patients, coworkers, and pharmacists’ family members during the COVID-19 pandemic. This cross-sectional, questionnaire-based research was conducted in Switzerland during the flu season and sent to all members of the Swiss Pharmacist Association. In December 2020, 569 community pharmacists completed the online survey. The influenza vaccination recommendation rates for high-risk patients were 93.6% for the elderly, 70.7% for pregnant women, 65.2% for immunocompromised people, and 60.3% for patients with chronic diseases. Pharmacists tend to recommend influenza immunization to patients more than to family members and colleagues. Holding a certification to administer immunization and personal influenza vaccine history were the main predictors for recommending influenza vaccination to patients, family members, and colleagues. Our results indicated that influenza vaccination recommendation rates in our whole sample of pharmacists, were higher for vaccinated and immunizing pharmacists. Ensuring high vaccinations rates and high ratio of immunizing pharmacists may be important in promoting seasonal influenza vaccination in the general population.

Impact of video-led educational intervention on the uptake of influenza vaccine among adults aged 60 years and above in China: a study protocol for a randomized controlled trial

Background

Influenza is a global health threat to older adults, and the influenza vaccine is the most effective approach to prevent influenza infection. However, influenza vaccination coverage among Chinese older adults is far less than in developed countries such as the United States (4.0% vs. 64.9%). This study aims to increase influenza vaccination coverage in Chinese adults ≥60 years using a video-led educational intervention conducted by medical students.

Methods

A cluster randomized controlled trial will be conducted in 4 districts of Xi’an city, Shaanxi Province, China, using a stratified sampling approach. Adults aged ≥60 years will be recruited from 8 community hospitals. A self-administered questionnaire of knowledge, attitudes, and practices (KAP) will be employed to record the KAP score. During the 6-month interventional period, participants in the intervention group will receive educational videos focused on influenza and influenza vaccination, coupled with a group discussion conducted by the medical students. For those in the control group, no intervention will be provided. The outcomes measured in both groups will be the influenza vaccination coverage and the KAP scores of all participants.

Discussion

Medical students are more likely to educate older adults about scientific knowledge of influenza and its vaccine compared to clinical practitioners, who, most of the time, remain over-occupied due to the extensive workload. Video-led counseling and education could be a useful option to optimize older adults’ understanding of influenza and influenza vaccination. This eventually could improve the uptake of influenza vaccine among Chinese older adults.

Trial registration

Chinese Clinical Trial Registry; ChiCTR2000034330; Registered 3rd July 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10220-1.

The intentions to get vaccinated against influenza and actual vaccine uptake among diabetic patients in Ningbo, China: identifying motivators and barriers

BACKGROUND

Health authorities recommend influenza vaccination to diabetic patients. Nevertheless, the vaccination coverage of adults was low in China. This study aimed to estimate influenza vaccination intentions and actual uptake among diabetic patients in China and identify the motivators and barriers associated with vaccination.

METHODS

During Nov 2016-Jan 2017, 1960 diabetic patients were invited to participate in the investigation about influenza vaccination based on health belief model (HBM). To link vaccination intention to behavior, a follow-up survey was conducted to collect vaccination records of the 2016-2017 season. Predictors of the motivation to obtain influenza vaccination were assessed using logistic regressions.

RESULTS

1914 diabetic patients completed the survey. 46.13% participants reported intentions to be vaccinated against influenza and 7.84% actually received vaccination. In the multivariate models, while all the domains of HBM constructs were associated with intentions, age, increasing numbers of comorbidity, urban residents, perceived susceptibility, perceived benefits, free vaccination, and vaccination history displayed positive associations with vaccine uptake while increasing income and perceptions of barriers were negative predictors of vaccine uptake. Besides, interactions between perceived susceptibility and healthcare workers' (HCW's) recommendation, perceived severity and benefits, perceived severity and health-seeking behaviors, perceived benefits, and influence of family/friends had a significant positive effect modification on the vaccine uptake.

CONCLUSION

To improve diabetic patients' influenza vaccination and close the intention-behavior gap, multipronged strategies are required not only to increase vaccination intention by promoting HCW's recommendation to improve perceptions about influenza vaccination but also facilitate a follow through on initial intentions by implementing free influenza vaccination program funded by the government.

An Exploratory Study of Influenza Vaccination Coverage in Healthcare Workers in a Western Chinese City, 2018-2019: Improving Target Population Coverage Based on Policy Interventions

Objectives: To evaluate a policy-based intervention to increase seasonal-influenza-vaccination coverage in healthcare workers in Xining, a city in Western China. Methods: From October 2018 to March 2019, we implemented a free vaccination policy in healthcare workers in Xining. A face-to-face interview with the head of the infection control department and an online survey for medical staff in four tertiary medical facilities was conducted to understand both the implementation of the free policy and influenza vaccination coverage. Possible factors for influenza vaccination among healthcare workers (physician, nurses working on the front-line, HCWs) were investigated by multivariate-logistic regression. Results: Coverage in two hospitals that implemented the free vaccination policy was 30.5% and 25.9%, respectively, which was statistically different to hospitals that did not implement the free policy (7.2% and 8.7%, respectively) (χ2 = 332.56, p < 0.0001). Among vaccinated healthcare workers, 65.5% and 48.6% reported their main reasons for vaccination were a convenient vaccination service and awareness of the free vaccination policy. The reasons for not being vaccinated among the 3389 unvaccinated healthcare workers included: the inconvenient vaccination service (33.8%), believing vaccination was unnecessary (29.7%), concerns about adverse reactions to the vaccine (28.8%), and having to pay for the vaccine (25.6%). Conclusions: Implementing the free vaccination policy, combined with improving the accessibility of the vaccination service, increased seasonal-influenza vaccination-coverage in healthcare workers in Xining.

Attitudes and perception of influenza vaccines among older people in Singapore: A qualitative study

Background

Despite recommendations for influenza vaccination of people aged 65 and above, uptake rate of influenza vaccines remains low.

This study aims to understand barriers and motivators behind older adult’s decision on influenza vaccination.

Methods

Face to face interviews with participants aged 65 and above were conducted and audio recorded in Geylang polyclinic in Singapore. Thematic content analysis was used to organise the data.

Results

15 older adults were interviewed, aged between 66 and 85 years old. 6 were vaccine refusers, 3 defaulters and 6 acceptors.

A perceived lack of vulnerability, fear of side effects, and trivialisation of influenza were common reasons for not taking the vaccine. Encouragement from family and friends, travel and previous positive vaccination experiences were motivators for getting vaccinated. Healthcare workers played a role in influencing many of the participants’ decision-making. Common misconceptions included vaccines considered as necessary only before travel and as a cure rather than prevention. Most participants exhibited ambivalence, giving reasons both for and against vaccine uptake.

Discussion

Most older adults do not perceive influenza as a potentially serious disease nor trust in influenza vaccines’ efficacy. Misconceptions played a significant role in vaccine decline. Novel findings include the importance of the family unit in decision making, prioritization of chronic health problems over vaccination and misconception that vaccines are only needed when travelling out of country. Healthcare workers and family members appear to be important influencers in the decision making of older adults and should be actively engaged in future health promotion initiatives.

Determinants of Willingness of Patients with Type 2 Diabetes Mellitus to Receive the Seasonal Influenza Vaccine in Southeast China

Willingness of patients with Type 2 diabetes mellitus (T2DM) to receive the seasonal influenza vaccine is low in China. A cross-sectional study on a representative sample of T2DM patients was conducted in Ningbo, a city in southeast China, to assess T2DM patients' willingness to be vaccinated against influenza and identify the influence factors of this willingness. Data regarding the participant's history of influenza, the knowledge, willingness and uptake of the influenza vaccine, demographic characteristics, reasons for willingness or unwillingness to be vaccinated was collected. Only 19.55% of a total of 1749 participants reported a willingness to be vaccinated. Factors positively associated with willingness to be vaccinated were perceived susceptibility to influenza (OR = 1.9, 95% CI: 1.5-2.5), awareness of the vaccine (OR = 1.7, 95% CI: 1.3-2.3) and previous history of influenza vaccination (OR = 4.4, 95% CI: 3.0-6.4). Patients with T2DM who were farmers (OR = 0.6, 95% CI: 0.4-0.8) and those managed by contracted family doctors (OR = 0.8, 95% CI: 0.6-1.0) expressed less willingness to be vaccinated. Targeted interventions such as enhancing health education and strengthening medical staff training should be conducted to increase T2DM patients' willingness to be vaccinated and enhance influenza vaccine uptake among this population.

Knowledge, attitude, and practice regarding infection and vaccination in patients with rheumatic diseases in China

Objective Vaccines including pneumococcal and influenza vaccines are recommended in patients with immunosuppressive treatment. However, vaccine coverage remains extremely low. Our study was to investigate vaccination uptake, knowledge, attitude and practice (KAP) towards certain vaccinations among these patients, and to identify the factors influencing willingness to be vaccinated. Methods A cross-sectional survey was conducted among patients with rheumatic diseases in a tertiary hospital in China. Baseline assessments were completed by using questionnaires including vaccination uptake and KAP towards certain infections and vaccinations. Results 235 patients completed the study. Mean age was 39.69 years old, while 66.4% were females. Only 6.4% of the participants once had taken vaccine in recent five years. One patient had influenza vaccination, and none ever took pneumococcal vaccine. 3.8% had doctor's recommendation on taking influenza, pneumococcal or herpes zoster vaccine. Major reasons given for not being vaccinated included "unnecessary" (8.9%) and "troublesome to take vaccines" (8.5%). Patients would take influenza or pneumococcal vaccines if they had heard of them before, had knowledge of infection, and had belief in vaccine's safety and reliability (p < 0.05). Conclusion Vaccine coverage among people with rheumatic diseases was low in China. Methods to improve KAP toward infections and vaccinations should be taken.

Determinants of healthcare workers' willingness to recommend the seasonal influenza vaccine to diabetic patients: A cross-sectional survey in Ningbo, China

Background: Seasonal influenza vaccine uptake among diabetic patients is low in China. Recent studies showed healthcare workers'(HCWs') recommendation is an effective way to promote influenza vaccination. This study aimed to assess HCWs' willingness to recommend influenza vaccine to diabetic patients and identify the predictors of this willingness. Methods: During Dec 2016-Jan 2017, a self-administered questionnaire on perceptions, attitudes and practices related to influenza vaccination for diabetic patients was distributed to 1370 HCWs in 20 hospitals and 20 community health centers in Ningbo. Predictors of HCWs' willingness to recommend influenza vaccine were analyzed by logistic regressions. Results: Of 1340 HCWs who completed the survey, 58.13%(779/1340) participants reported willingness to recommend influenza vaccine to diabetic patients. Factors positively associated with the recommendation willingness included awareness of national influenza vaccination guideline(OR: 6.33; 95%CI: 4.66-8.60) and regional reimbursement policy(OR: 1.62; 95%CI: 1.19-2.20), training on influenza and diabetes (OR: 1.65; 95%CI: 1.21-2.23), influenza vaccination history(OR: 1.35; 95%CI: 1.01-1.79), beliefs in vaccine effects on reducing serious consequences(OR: 1.38; 95%CI: 1.01-1.91), reduction in hospitalization costs(OR: 1.43; 95%CI: 1.05-1.94) caused by influenza, and more than 10 years of practitioner experience(OR: 1.60; 95%CI: 1.04-2.46). Worries about side-effects of influenza vaccine were identified as the barriers of recommendation. Conclusion: The present study demonstrates that knowledge about national guideline and reimbursement policies, training programs, perceptions about effectiveness and safety of influenza vaccine increase HCWs' willingness to recommend the influenza vaccination to diabetic patients. These measures should be taken to ensure HCWs' role in the administration of influenza vaccination among diabetic patients.

Low coverage rate and awareness of influenza vaccine among older people in Shanghai, China: A cross-sectional study

Background: Older individuals are at high risk for morbidity and mortality due to influenza, and the most effective way to prevent influenza is yearly vaccination. In China, the influenza vaccine is not covered by the national Expanded Program on Immunization, and more evidence is needed about influenza vaccine usage among older individuals.

Objective: To determine the influenza vaccination coverage and its influencing factors, and understand barriers to older adults receiving influenza vaccinations in Shanghai, China.

Methods: A cross-sectional survey was conducted with residents aged 60 and older. Vaccination status in the 2016–17 influenza season and reasons for or against vaccination were surveyed. The vaccination coverage rates were adjusted by gender, age and community distribution, and potential factors influencing vaccination uptake were determined by bivariate logistic regression.

Results: In total, 253 of the 4417 respondents received an influenza vaccine during the 2016–17 season, yielding an adjusted coverage rate of 5.2% (95% CI, 4.5-5.8). The frequency of receiving the vaccine was higher for older individuals living with family/friends than that for those living alone (p < 0.05), and lower among individuals with chronic respiratory diseases (p < 0.05). Among unvaccinated respondents, lack of influenza vaccine awareness was the most common reason for being unvaccinated (48.3%, 2012/4164).

Conclusion: Influenza vaccination coverage is extremely low among older people in Shanghai, and lack of awareness of the influenza vaccine might be a potential barrier to vaccination. Our study highlights the need for an appropriate influenza vaccination strategy and program targeting the older population.