Influenza vaccination in long-term-care facilities: structuring programs for success

Influenza immunization of healthcare personnel in the post-COVID-19 pandemic era: Still a lot to do!

Healthcare-associated influenza is frequently encountered in healthcare settings with significant morbidity and mortality among vulnerable patients, absenteeism among healthcare personnel (HCP), and interruption of healthcare services. Numerous investigations indicate that nosocomial outbreaks are often traced to HCP. Despite the international and national endorsements, seasonal influenza vaccine acceptance among HCP continues suboptimal worldwide. Infection control is the major objective for healthcare risk management in order to guarantee patient safety, limit the cost of hospitalization and assurance health management in controlling influenza seasons. Vigilance and anticipation are required as globally we are moving from a reactive COVID-19 pandemic response phase to one of planning for the co-circulation of viral respiratory infections. Declining to understand HCP perception of influenza risk and acceptance of vaccination might have impact patient safety as well as healthcare services.

Utility of Healthcare System-Based Interventions in Improving the Uptake of Influenza Vaccination in Healthcare Workers at Long-Term Care Facilities: A Systematic Review

Healthcare workers (HCWs) in long-term care facilities (LTCFs) can represent a source of influenza infection for the elderly. While flu vaccination coverage (VC) is satisfactory in the elderly, HCWs are less likely to be vaccinated. There is no definitive evidence on which types of healthcare system-based interventions at LTCFs would be more useful in improving the vaccination uptake among HCWs. We performed a systematic review in different databases (Pubmed, Cochrane Database of Systematic Reviews, Health Evidence, Web of Science, Cinahl) to provide a synthesis of the available studies on this topic. Among the 1177 articles screened by their titles and abstracts, 27 were included in this review. Most of the studies reported multiple interventions addressed to improve access to vaccination, eliminate individual barriers, or introduce policy interventions. As expected, mandatory vaccinations seem to be the most useful intervention to increase the vaccination uptake in HCWs. However, our study suggests that better results in the vaccination uptake in HCWs were obtained by combining interventions in different areas. Educational campaigns alone could not have an impact on vaccination coverage. LTCFs represent an ideal setting to perform preventive multi-approach interventions for the epidemiological transition toward aging and chronicity.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase influenza vaccination uptake in people aged 60 years and older varies by country and participant characteristics. This review updates versions published in 2010 and 2014.

OBJECTIVES

To assess access, provider, system, and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL, which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE, Embase, CINAHL, and ERIC for this update, as well as WHO ICTRP and ClinicalTrials.gov for ongoing studies to 7 December 2017. We also searched the reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and cluster-randomised trials of interventions to increase influenza vaccination in people aged 60 years or older in the community.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as specified by Cochrane.

MAIN RESULTS

We included three new RCTs for this update (total 61 RCTs; 1,055,337 participants). Trials involved people aged 60 years and older living in the community in high-income countries. Heterogeneity limited some meta-analyses. We assessed studies as at low risk of bias for randomisation (38%), allocation concealment (11%), blinding (44%), and selective reporting (100%). Half (51%) had missing data. We assessed the evidence as low-quality. We identified three levels of intervention intensity: low (e.g. postcards), medium (e.g. personalised phone calls), and high (e.g. home visits, facilitators).Increasing community demand (12 strategies, 41 trials, 53 study arms, 767,460 participants)One successful intervention that could be meta-analysed was client reminders or recalls by letter plus leaflet or postcard compared to reminder (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15; 3 studies; 64,200 participants). Successful interventions tested by single studies were patient outreach by retired teachers (OR 3.33, 95% CI 1.79 to 6.22); invitations by clinic receptionists (OR 2.72, 95% CI 1.55 to 4.76); nurses or pharmacists educating and nurses vaccinating patients (OR 152.95, 95% CI 9.39 to 2490.67); medical students counselling patients (OR 1.62, 95% CI 1.11 to 2.35); and multiple recall questionnaires (OR 1.13, 95% CI 1.03 to 1.24).Some interventions could not be meta-analysed due to significant heterogeneity: 17 studies tested simple reminders (11 with 95% CI entirely above unity); 16 tested personalised reminders (12 with 95% CI entirely above unity); two investigated customised compared to form letters (both 95% CI above unity); and four studies examined the impact of health risk appraisals (all had 95% CI above unity). One study of a lottery for free groceries was not effective.Enhancing vaccination access (6 strategies, 8 trials, 10 arms, 9353 participants)We meta-analysed results from two studies of home visits (OR 1.30, 95% CI 1.05 to 1.61) and two studies that tested free vaccine compared to patient payment for vaccine (OR 2.36, 95% CI 1.98 to 2.82). We were unable to conduct meta-analyses of two studies of home visits by nurses plus a physician care plan (both with 95% CI above unity) and two studies of free vaccine compared to no intervention (both with 95% CI above unity). One study of group visits (OR 27.2, 95% CI 1.60 to 463.3) was effective, and one study of home visits compared to safety interventions was not.Provider- or system-based interventions (11 strategies, 15 trials, 17 arms, 278,524 participants)One successful intervention that could be meta-analysed focused on payments to physicians (OR 2.22, 95% CI 1.77 to 2.77). Successful interventions tested by individual studies were: reminding physicians to vaccinate all patients (OR 2.47, 95% CI 1.53 to 3.99); posters in clinics presenting vaccination rates and encouraging competition between doctors (OR 2.03, 95% CI 1.86 to 2.22); and chart reviews and benchmarking to the rates achieved by the top 10% of physicians (OR 3.43, 95% CI 2.37 to 4.97).We were unable to meta-analyse four studies that looked at physician reminders (three studies with 95% CI above unity) and three studies of facilitator encouragement of vaccination (two studies with 95% CI above unity). Interventions that were not effective were: comparing letters on discharge from hospital to letters to general practitioners; posters plus postcards versus posters alone; educational reminders, academic detailing, and peer comparisons compared to mailed educational materials; educational outreach plus feedback to teams versus written feedback; and an intervention to increase staff vaccination rates.Interventions at the societal levelNo studies reported on societal-level interventions.Study funding sourcesStudies were funded by government health organisations (n = 33), foundations (n = 9), organisations that provided healthcare services in the studies (n = 3), and a pharmaceutical company offering free vaccines (n = 1). Fifteen studies did not report study funding sources.

AUTHORS' CONCLUSIONS

We identified interventions that demonstrated significant positive effects of low (postcards), medium (personalised phone calls), and high (home visits, facilitators) intensity that increase community demand for vaccination, enhance access, and improve provider/system response. The overall GRADE assessment of the evidence was moderate quality. Conclusions are unchanged from the 2014 review.

Influenza Immunization in Nursing Homes: Who Does Not Get Immunized and Whose Status Is Unknown?

Objective.

To identify nursing home resident and facility characteristics associated with patients not receiving influenza immunization and having unknown immunization status.

Design.

Secondary data analysis using multinomial logistic regression of data from the National Nursing Home Survey, a nationally representative establishment-based survey.

Setting.

A total of 1,423 nursing facilities of all ownerships and certifications systematically sampled with probability proportional to number of beds.

Patients.

A total of 7,350 randomly sampled people aged 65 years or older residing in nursing homes between July and December 1999 (approximately 6 per facility).

Main Outcome Measure.

Immunization status of residents.

Results.

Fifteen percent of residents were not immunized and 19% had unknown immunization status. In multivariate analysis, lack of immunization and unknown immunization status were each separately associated with being newly admitted, with no or unknown pneumococcal immunization, and with facility failures to screen for immunization and to record inoculation in the medical record. High-risk status and staff immunization requirements had no effect. Separate analyses showed that residents with unknown immunization status are statistically significantly different from both those vaccinated and those not vaccinated.

Conclusion.

This study indicates that both resident and facility characteristics are associated with failure to be immunized for influenza. Facilities should consider targeting younger, newly admitted, and residential care residents for influenza immunization, since they are more likely to be missed. Further research into the barriers to immunization specific to nursing home resident choice or opportunity may be warranted.

Inducing Herd Immunity against Seasonal Influenza in Long-Term Care Facilities through Employee Vaccination Coverage: A Transmission Dynamics Model

Introduction. Vaccinating healthcare workers (HCWs) in long-term care facilities (LTCFs) may effectively induce herd immunity and protect residents against influenza-related morbidity and mortality. We used influenza surveillance data from all LTCFs in New Mexico to validate a transmission dynamics model developed to investigate herd immunity induction. Material and Methods. We adjusted a previously published transmission dynamics model and used surveillance data from an active system among 76 LTCFs in New Mexico during 2006-2007 for model validation. We used a deterministic compartmental model with a stochastic component for transmission between residents and HCWs in each facility in order to simulate the random variation expected in such populations. Results. When outbreaks were defined as a dichotomous variable, our model predicted that herd immunity could be induced. When defined as an attack rate, the model demonstrated a curvilinear trend, but insufficiently strong to induce herd immunity. The model was sensitive to changes in the contact parameter β but was robust to changes in the visitor contact probability. Conclusions. These results further elucidate previous studies' findings that herd immunity may not be induced by vaccinating HCWs in LTCFs; however, increased influenza vaccination coverage among HCWs reduces the probability of influenza infection among residents.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

OBJECTIVES

To assess access, provider, system and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

Understanding health care personnel's attitudes toward mandatory influenza vaccination

BACKGROUND

This study investigated the factors influencing influenza vaccination rates among health care personnel (HCP) and explored HCP's attitudes toward a policy of mandatory vaccination.

METHODS

In September 2012, a 33-item Web-based questionnaire was administered to 3,054 HCP employed at a tertiary care hospital in metropolitan Detroit.

RESULTS

There was a significant increase in the rate of influenza vaccination, from 80% in the 2010-2011 influenza season (before the mandated influenza vaccine) to 93% in 2011-2012 (after the mandate) (P < .0001). Logistic regression showed that HCP with a history of previous influenza vaccination were 7 times more likely than their peers without this history to receive the vaccine in 2011-2012. A pro-mandate attitude toward influenza vaccination was a significant predictor of receiving the vaccine after adjusting for demographics, history of previous vaccination, awareness of the hospital's mandatory vaccination policy, and patient contact while providing care (P = .01).

CONCLUSIONS

The increased rate of influenza vaccination among HCP was driven by both an awareness of the mandatory policy and a pro-mandate attitude toward vaccination. The findings of this study call for better education of HCP on the influenza vaccine along with enforcement of a mandatory vaccination policy.

Influenza and seasonal patterns of hospital use by older adults in long-term care and community settings in Ontario, Canada

OBJECTIVES

We compared seasonal influenza hospital use among older adults in long-term care (LTC) and community settings.

METHODS

We used provincial administrative data from Ontario to identify all emergency department (ED) visits and hospital admissions for pneumonia and influenza among adults older than 65 years between 2002 and 2008. We used sentinel laboratory reports to define influenza and summer seasons and estimated mean annual event rates and influenza-associated rates.

RESULTS

Mean annual pneumonia and influenza ED visit rates were higher in LTC than the community (rate ratio [RR] for influenza season = 3.9; 95% confidence interval [CI] = 3.8, 4.0; for summer = 4.9; 95% CI = 4.8, 5.1) but this was attenuated in influenza-associated rates (RR = 2.4; 95% CI = 2.1, 2.8). The proportion of pneumonia and influenza ED visits attributable to seasonal influenza was 17% (15%-20%) in LTC and 28% (27%-29%) in the community. Results for hospital admissions were comparable.

CONCLUSIONS

We found high rates of hospital use from LTC but evidence of lower impact of circulating influenza in the community. This differential impact of circulating influenza between the 2 environments may result from different influenza control policies.

Importance of employee vaccination against influenza in preventing cases in long-term care facilities

OBJECTIVE

Employees of long-term care facilities (LTCFs) who have contact with residents should be vaccinated against influenza annually to reduce influenza incidence among residents. This investigation estimated the magnitude of the benefit of this recommendation.

METHODS

The New Mexico Department of Health implemented active surveillance in all of its 75 LTCFs during influenza seasons 2006-2007 and 2007-2008. Information about the number of laboratory-confirmed cases of influenza and the proportion vaccinated of both residents and direct-care employees in each facility was collected monthly. LTCFs reporting at least 1 case of influenza (defined alternately by laboratory confirmation or symptoms of influenza-like illness [ILI]) among residents were compared with LTCFs reporting no cases of influenza. Regression modeling was used to obtain adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between employee vaccination coverage and the occurrence of influenza outbreaks. Covariates included vaccination coverage among residents, the staff-to-resident ratio, and the proportion of filled beds.

RESULTS

Seventeen influenza outbreaks were reported during this 2-year period of surveillance. Eleven of these were laboratory confirmed (n = 21 residents) and 6 were defined by ILI (n = 40 residents). Mean influenza vaccination coverage among direct-care employees was 51% in facilities reporting outbreaks and 60% in facilities not reporting outbreaks (P = .12). Increased vaccination coverage among direct-care employees was associated with fewer reported outbreaks of laboratory-confirmed influenza (aOR, 0.97 [95% CI, 0.95-0.99]) and ILI (aOR, 0.98 [95% CI, 0.96-1.00]).

CONCLUSIONS

High vaccination coverage among direct-care employees helps to prevent influenza in LTCFs.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

Influenza vaccination among healthcare workers: ten-year experience of a large healthcare organization

OBJECTIVE

To describe the results of different measures implemented to improve adherence to the healthcare worker (HCW) influenza immunization program at BJC HealthCare during the period from 1997 through 2007.

DESIGN

Descriptive retrospective study.

SETTING

BJC HealthCare, a 13-hospital nonprofit healthcare organization in the Midwest.

METHODS

We reviewed and analyzed HCW influenza vaccination data from all BJC HealthCare Occupational Health Services and hospitals during the period from 1997 through 2007. Occupational health staff, infection prevention personnel, and key influenza vaccination campaign leaders were also interviewed regarding implementation measures during the study years.

RESULTS

At the end of 2007, BJC HealthCare had approximately 26,000 employees. With the use of multiple progressive interventions, influenza vaccination rates among BJC employees increased from 45% in 1997 to 72% in 2007 (P < .001). The influenza vaccination rate in 2007 was significantly higher than in 2006: 72%, compared with 54% (P < .001). Five hospitals had influenza vaccination rates that exceeded the target goal of 80% in 2007. The most successful interventions were adding influenza vaccination rates to the quality scorecard incentive program and the use of declination statements, both of which were implemented in 2007. The most important barriers to success identified by interview respondents were HCWs' misconceptions about influenza vaccination and a perceived lack of leadership support.

CONCLUSIONS

Influenza vaccination rates among HCWs significantly improved with multiple interventions over the years. However, the BJC HealthCare influenza vaccination target of 80% was not attained at all hospitals with these measures. More aggressive interventions, such as implementing mandatory influenza vaccination policies, are needed to achieve higher vaccination rates.

Influenza vaccine uptake among staff in care homes in Nottinghamshire: a random cluster sample survey

OBJECTIVES

To establish uptake of influenza vaccine amongst care home clinical staff in Greater Nottingham, and to investigate what could be done to improve vaccine uptake in this group.

STUDY DESIGN

Postal questionnaire surveys were used. In the first instance, a total sample survey was used. In the second instance, a sample of care home staff was surveyed, randomized at the care home level.

METHODS

A postal questionnaire completed by care home matrons was used to obtain a preliminary estimate of staff vaccine uptake. Individual staff questionnaires were then used to validate this finding, and measure attitudes, beliefs and behaviours associated with vaccination.

RESULTS

Vaccine uptake among those working in care homes with nursing was found to be low. Vaccine uptake was higher in homes with a policy recommending vaccination of staff. Most respondents who had received vaccination reported that they had done so because of an existing medical condition, rather than because of being a healthcare worker. A statistically significant relationship (P=0.02) was found between individuals' reported beliefs on how well they could resist influenza and their vaccination status.

CONCLUSIONS

All care homes for the elderly should have a vaccination policy which recommends staff vaccination. Educational campaigns, vaccination in the workplace and free provision of the influenza vaccine may help to improve vaccine uptake in this group.

[Influenza vaccination in healthcare workers. Why are some vaccinated whereas others are not]

BACKGROUND AND OBJECTIVE

Influenza vaccination is indicated in health professionals. Nevertheless, vaccination coverage in healthcare workers tends to be low. This paper determines the reasons why some workers are vaccinated whereas others are not and investigates what type of intervention can modify the latter attitude.

METHOD

This was a cross-sectional descriptive study using a questionnaire survey.

SETTING

workers at Hospital General Universitario de Alicante (Alicante, Spain). Absolute frequencies and relative frequencies expressed in percentages were calculated for each of the variables studied. Results were analyzed considering the professional categories of the persons involved and the departments where they worked.

RESULTS

The reasons for influenza vaccination stated by hospital workers were to protect their health (65.6%), the belief that vaccination is beneficial (45.7%), and to avoid transmitting influenza to their patients (42.5%), and to their own families (39.8%). The main reasons for not undergoing vaccination were to avoid medication (17.9%), confidence in their own defenses (17%), or fear of the secondary effects of the vaccine (16.8%).

CONCLUSION

The main reason given by hospital personnel for undergoing vaccination was to protect their own health and that of their family and patients. The reasons most frequently given for not undergoing vaccination were based on possible side effects of the vaccine, the conviction of not being part of a high-risk group, and doubts about the effectiveness of the vaccine as a protective agent. Many of the reasons given for not undergoing vaccination were based on erroneous beliefs and should be taken into account when designing strategies to increase influenza vaccination coverage among health personnel.

Mass vaccination for annual and pandemic influenza

Influenza virus causes annual epidemics and occasional pandemics. Frequent mutations in circulating influenza strains ("antigenic drift") result in the need for annual vaccination. More than two-thirds of persons in the U.S. are recommended for annual vaccination. Because influenza vaccine is available seasonally, mass vaccination strategies are well suited to its delivery. Although doctors offices are the most frequent setting for influenza vaccination overall, workplaces, clinics, and community sites (retail stores and pharmacies) also are common vaccination settings. Influenza vaccination also is delivered in mass vaccination clinics to health care workers and military personnel. Universal influenza vaccination, which has been recommended as a strategy to improve prevention by increasing vaccination coverage and providing indirect protection of adults by decreasing infection and transmission among children, would require expanded use of mass vaccination, for example in schools, as well as in the community. Influenza pandemics occur when a new influenza A subtype is introduced into the population ("antigenic shift"). Most or all of the population is susceptible to the pandemic virus and two doses of vaccine may be needed for protection. U.S. pandemic preparedness and response plans indicate that the entire population should be vaccinated beginning with defined priority groups including those who provide essential services including healthcare and those at highest risk of severe illness and death. Pandemic influenza vaccination will occur primarily through the public sector in mass clinic settings. Vaccination program planning must consider issues including coordination, staffing, clinic location and lay-out, security, record keeping, and communications. Exercising vaccination clinics is important for preparedness and can be done in the context of annual influenza vaccination.

Factors that affect influenza vaccine uptake among staff of long-term care facilities

A survey of directors and employees of 36 long-term care facilities in Hesse, Germany, revealed that influenza vaccine uptake among staff was less than 30% in 30 and greater than 50% in 6. The study identified policies and practices associated with vaccination uptake at long-term care facilities and factors associated with the decision of staff to get vaccinated.

Prevalence of influenza vaccination in South Australian aged care homes

OBJECTIVE

To determine the prevalence of influenza immunisation of residents within South Australian aged care homes, reasons why vaccination is not given, the policy associated with vaccination administration and the source of the vaccination.

METHOD

A clustered, multistage, area sample was used to assess the provision of the influenza vaccine to 500 randomly selected residents within 50 randomly selected aged care homes in South Australia during face-to-face interviews with the director of nursing at each of the selected facilities. The response rate was 100%.

RESULTS

Overall, 88.4% (95% CI 85.2-91.0) of residents had received an influenza immunisation in 2001. The reasons why a resident did not have an influenza vaccination included refusal and allergy. Consent was generally obtained on an ad hoc basis (in 94.0% of homes) with the most frequent form of consent type being verbal (66.0%). Influenza vaccine administration was part of standing drug orders in 16.0% of cases and over half of the homes (54.0%) had a specific policy of education and encouraging both residents and staff to be vaccinated against influenza.

CONCLUSION

Residents of aged care homes, a population deemed to be at high risk of contracting influenza, are receiving an adequate level of influenza coverage although improvements could be made. Addressing policy and procedural issues can maintain, and further improve, vaccination levels.

IMPLICATIONS

Clarification of policies for influenza vaccination administration particularly in regard to staff could further improve rates of vaccination coverage.

A collaborative system-wide response to influenza outbreak management in Saskatoon Health Region

OBJECTIVE

To describe the benefits of a regional, collaborative, system-wide approach to influenza outbreak management.

PARTICIPANTS

Senior management representatives from affected parts of the Regional Health Authority.

SETTING

Saskatoon Health Region.

INTERVENTION

Public Health proactively engaged a broad-based, multidisciplinary planning/management group to minimize the effect of the influenza outbreak, and institute best practice in prevention and outbreak management system-wide for the future.

OUTCOMES

Earlier recognition and faster resolution of influenza outbreaks, fewer outbreaks, reduced pressure on acute care, greater compliance with amantadine prophylaxis, and improved immunization rates in seniors and health care workers.

CONCLUSION

While many of these interventions and best practices have been recommended by individual sectors, when Public Health takes a system-wide approach facilitated by regionalization, it results in optimized planning, co-ordination, evaluation and successful outcomes.

Hospitalizations and Deaths Due to Respiratory Illnesses During Influenza Seasons: A Comparison of Community Residents, Senior Housing Residents, and Nursing Home Residents

BACKGROUND

Although research indicates that influenza is a major cause of morbidity and mortality among older adults, few studies have tried to identify which seniors are particularly at risk of experiencing complications of influenza. The purpose of this study was to compare hospitalizations and deaths due to respiratory illnesses during influenza seasons among seniors (aged 65+) living in the community, senior residences (apartments reserved for seniors), and nursing homes.

METHODS

Using administrative data, all hospital admissions and deaths due to respiratory illnesses (pneumonia and influenza, chronic lung disease, and acute respiratory diseases) were identified for all individuals aged 65 and older living in Winnipeg, Canada (approximately 88,000 individuals) during four influenza seasons (1995-1996 to 1998-1999).

RESULTS

Hospitalization and death rates for respiratory illnesses increased significantly during influenza seasons, compared to fall periods (e.g., 42.7 vs 25.2 hospitalizations per 1000 population aged 80 and older). Moreover, hospitalization rates for pneumonia and influenza, chronic lung disease, and acute respiratory diseases were higher among individuals living in senior residences (42.5 per 1000 for all respiratory illnesses combined) than their counterparts living in the community (22.8 per 1000). Furthermore, deaths due to pneumonia and influenza and chronic lung disease were higher among senior housing residents (4.2 per 1000) than community residents (2.6 per 1000) and were particularly high among nursing home residents (52.1 per 1000).

CONCLUSIONS

Individuals living in seniors residences are at increased risk of being hospitalized for and dying of respiratory illnesses during influenza seasons. Given that influenza vaccination is currently the best method to reduce influenza-associated illnesses among seniors, this suggests that influenza vaccination strategies should be targeted at this population.

Influenza and pneumococcal vaccination coverage levels among Hawaii statewide long-term-care facilities

Influenza and pneumococcal vaccination rates among Hawaii long-term-care facilities (LTCFs) statewide during the 1996/97 through the 1998/99 influenza seasons revealed that resident influenza vaccination rates remained over 89%, but pneumococcal vaccination was underutilized. LTCF staff influenza vaccination rates over the same time period were low.

Immunogenicity and safety of three commercial influenza vaccines in institutionalized elderly

Influenza is a leading cause of morbidity and mortality in elderly people. This prospective, observed-blind, randomized, multicenter trial compares the immunogenicity and safety of three influenza vaccines in a sample of 635 elderly residents of four nursing homes in Milano (Italy). All vaccines were well tolerated: no serious adverse events were recorded, and a small number (9 subjects) of local and systemic reactions were observed. Twenty-nine oropharyngeal swabs were taken during the season from ILI (influenza-like illness) patients, none of whom was positive for influenza and other respiratory viruses. Immunogenicity was evaluated in a subgroup of 111 subjects with blood samples obtained just before vaccination and after 4 and 12 weeks. The adjuvanted vaccines, subunit vaccine with MF59 (a-SUV) and virosome subunit vaccine (v-SUV), induced a higher antibody response than whole virus vaccine (WVV). There was no significant difference between groups that received a-SUV and v-SUV, but the a-SUV group had higher values of geometric mean titres than the v-SUV group for H1N1 and B influenza strains. These findings suggest that influenza vaccination is effective, and they underscore the importance of vaccination programs for institutionalized elderly. Further studies are needed to compare other adjuvanted vaccines in order to define their different properties.

Control of influenza A on a bone marrow transplant unit

In January 1998, an outbreak of influenza A occurred on our adult bone marrow transplant unit. Aggressive infection control measures were instituted to halt further nosocomial spread. A new, more rigorous approach was implemented for the 1998/99 influenza season and was extremely effective in preventing nosocomial influenza at our institution.