Strategies used to improve vaccine uptake among healthcare providers: A systematic review

Background

Vaccination is one of the most effective available public health tools, preventing infectious diseases to safeguard public health and save millions of lives annually. However, in recent years vaccine hesitancy has increased among all populations, including healthcare workers. Healthcare providers are central to vaccination efforts due to their increased exposure to disease and vulnerable patients, and their role in patient confidence and decision-making. These decreasing uptake rates highlight a critical need to address specific barriers within this target group. This systematic review aims to explore the strategies used to improve vaccine uptake among healthcare providers.

Methods

A literature search was conducted in PubMed, EMBASE, and MEDLINE databases, alongside a grey literature search, to identify studies describing interventions to improve vaccine uptake among healthcare providers. This was followed by de-duplication and double-blinded screening processes using Rayyan. Data extraction and thematic analysis focused on categorising interventions and identifying frequencies of use, to develop recommendations for further interventions tailored to target regions.

Results

60 studies were identified, predominantly concerning influenza vaccination. Interventions included educational initiatives, reminders, incentives, access solutions, feedback, and policy implementation. Key strategies included targeted educational lectures, posters, and pamphlets; mobile vaccination units; extended vaccination hours; and leadership engagement. The findings underscore the importance of a multifaceted approach combining educational efforts, enhanced accessibility, and motivational incentives to improve vaccination rates within the healthcare providers, especially where mandatory vaccination is controversial.

Conclusions

This review evaluates tailored strategies to enhance vaccine confidence and uptake among healthcare providers, advocating for a holistic approach that includes educational initiatives, reminder systems, incentives, improved access, feedback mechanisms, and policy enactment to effectively address hesitancy and promote public health.

Effectiveness of interventions to increase healthcare workers' adherence to vaccination against vaccine-preventable diseases: a systematic review and meta-analysis, 1993 to 2022

BackgroundVaccination adherence among healthcare workers (HCWs) is fundamental for the prevention of vaccine-preventable diseases (VPDs) in healthcare. This safeguards HCWs' well-being, prevents transmission of infections to vulnerable patients and contributes to public health.AimThis systematic review and meta-analysis aimed to describe interventions meant to increase HCWs' adherence to vaccination and estimate the effectiveness of these interventions.MethodsWe searched literature in eight databases and performed manual searches in relevant journals and the reference lists of retrieved articles. The study population included any HCW with potential occupational exposure to VPDs. We included experimental and quasi-experimental studies presenting interventions aimed at increasing HCWs' adherence to vaccination against VPDs. The post-intervention vaccination adherence rate was set as the main outcome. We included the effect of interventions in the random-effects and subgroup meta-analyses.ResultsThe systematic review considered 48 studies on influenza and Tdap vaccination from database and manual searches, and 43 were meta-analysed. A statistically significant, positive effect was seen in multi-component interventions in randomised controlled trials (relative risk (RR) = 1.37; 95% CI: 1.13-1.66) and in observational studies (RR = 1.43; 95% CI: 1.29-1.58). Vaccination adherence rate was higher in community care facilities (RR = 1.58; 95% CI: 1.49-1.68) than in hospitals (RR = 1.24; 95% CI: 0.76-2.05).ConclusionInterventions aimed at increasing HCWs' adherence to vaccination against VPDs are effective, especially multi-component ones. Future research should determine the most effective framework of interventions for each setting, using appropriate study design for their evaluation, and should compare intervention components to understand their contribution to the effectiveness.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Identifying reasons for non-acceptance of influenza vaccine in healthcare workers: an observational study using declination form data

BACKGROUND

Healthcare workers are sometimes required to complete a declination form if they choose not to accept the influenza vaccine. We analysed the declination data with the goal of identifying barriers to vaccination uptake across seasons, staff groups, and pre- and post- arrival of COVID-19.

METHODS

Reasons for declining the vaccine were gathered from N = 2230 declination forms, collected over four influenza seasons, 2017/2018, 2018/2019, 2019/2020 and 2020/2021, from a single health board in the UK. Reasons were classified according to ten categories and the resulting distribution analysed across year and staff groups. A further analysis considered the two most prevalent categories in more detail.

RESULTS

Fear of adverse reactions and Lack of perception of own risk were identified as primary reasons for not accepting the vaccine across time and across staff groups. However, there was no evidence that Lack of concern with influenza, or Doubts about vaccine efficacy was prevalent, contrary to previous findings. Overall, reasons fitted a pattern of underestimating risk associated with influenza and overestimating risk of minor adverse reactions. There were also differences across years, χ2(24) = 123, p < .001. In particular, there were relatively fewer Lack of perception of own risk responses post-COVID-19 arrival than before, χ2(8) = 28.93, p = .002.

CONCLUSION

This study shows that data collected from declination forms yields sensible information concerning vaccine non-acceptance without the difficulties of retrospective or pre-emptive reasoning suffered by questionnaires. Our findings will aid messaging campaigns designed to encourage uptake of the influenza vaccine in healthcare workers. In particular, we argue for an approach focused on risk perception rather than correction of straightforward misconceptions.

Uptake of Influenza Vaccine and Factors Associated with Influenza Vaccination among Healthcare Workers in Tertiary Care Hospitals in Bangladesh: A Multicenter Cross-Sectional Study

Influenza, highly contagious in hospital settings, imposes a substantial disease burden globally, and influenza vaccination is critical for healthcare workers (HCWs) to prevent this illness. This study assessed influenza vaccine uptake, including its associated factors among HCWs of tertiary care hospitals in Bangladesh. Between September and December 2020, this multicenter study included 2046 HCWs from 11 hospitals. Face-to-face interviews were conducted using a semi-structured questionnaire to collect data from physicians, nurses, and cleaning and administrative staff for the survey. Only 13.8% (283/2046) of HCWs received the influenza vaccine, of which the majority (76.7%, 217/283) received it for free from the hospital. Nurses had the highest (20.0%, 187/934) influenza vaccine coverage, followed by physicians at 13.5% (71/526), whereas cleaning staff had the lowest at 6.0% (19/318). Among unvaccinated HCWs, the desire to get vaccinated was high (86.2%), with half of the respondents even being willing to pay for it. The HCWs who were aware of the influenza vaccine were over five times more likely to get the vaccine (OR 5.63; 95% CI: 1.04, 1.88) compared to those who were not. HCWs in Bangladesh were vaccinated against influenza at a very low rate. Free and mandatory influenza vaccination programs should be initiated to optimize vaccine coverage among HCWs.

'Leading from the front' implementation increases the success of influenza vaccination drives among healthcare workers: a reanalysis of systematic review evidence using Intervention Component Analysis (ICA) and Qualitative Comparative Analysis (QCA)

BACKGROUND

Seasonal influenza vaccination of healthcare workers (HCW) is widely recommended to protect staff and patients. A previous systematic review examined interventions to encourage uptake finding that hard mandates, such as loss of employment for non-vaccination, were more effective than soft mandates, such as signing a declination form, or other interventions such as incentives. Despite these overarching patterns the authors of the review concluded that 'substantial heterogeneity' remained requiring further analysis. This paper reanalyses the evidence using Intervention Component Analysis (ICA) and Qualitative Comparative Analysis (QCA) to examine whether the strategies used to implement interventions explain the residual heterogeneity.

METHODS

We used ICA to extract implementation features and trialists' reflections on what underpinned the success of the intervention they evaluated. The ICA findings then informed and structured two QCA analyses to systematically examine associations between implementation features and intervention outcomes. Analysis 1 examined hard mandate studies. Analysis 2 examined soft mandates and other interventions.

RESULTS

In Analysis 1 ICA revealed the significance of 'leading from the front' rather than 'top-down' implementation of hard mandates. Four key features underpinned this: providing education prior to implementation; two-way engagement so HCW can voice concerns prior to implementation; previous use of other strategies so that institutions 'don't-go-in-cold' with hard-mandates; and support from institutional leadership. QCA revealed that either of two configurations were associated with greater success of hard mandates. The first involves two-way engagement, leadership support and a 'don't-go-in-cold' approach. The second involves leadership support, education and a 'don't-go-in-cold' approach. Reapplying the 'leading from the front' theory in Analysis 2 revealed similar patterns.

CONCLUSIONS

Regardless of intervention type a 'leading from the front' approach to implementation will likely enhance intervention success. While the results pertain to flu vaccination among HCWs, the components identified here may be relevant to public health campaigns regarding COVID-19 vaccination.

Influence of critically appraising exemption requests from healthcare personnel along a spectrum of influenza vaccine hesitancy

Objectives:

This study was performed to assess whether an intervention for critically appraising influenza vaccine exemption requests from healthcare personnel (HCP) affected (1) the overall rate of influenza vaccine exemption within a healthcare institution and/or (2) the rates of postintervention vaccine acceptance among those who inconsistently request exemption from annual vaccination and those who consistently request exemption from vaccination.

Design:

Retrospective, before-and-after intervention study.

Setting:

We conducted the study at a single academic medical center.

Participants:

This study included 29,663 HCP.

Methods:

Between 2010 and 2019, HCP were permitted to request an exemption from influenza vaccination without critical appraisal of exemption requests. After January 2019, medical center policy required critical appraisal of exemption requests. Of those employed 3 or more years who requested an exemption at least once during the preintervention period (n = 1,177), those with unchanging exemption reasons annually were termed “consistent exempters.” Those who changed reasons or accepted vaccination n ≥ 1 times were termed “inconsistent exempters.”

Results:

The overall exemption rate from influenza vaccine decreased from 3.8% to 1.2% (P < .001; N = 29,663) after the intervention. Of those requesting exemption at least once before the intervention, 329 (28.0%) of 1,177 were consistent exempters and 878 (72.0%) were inconsistent exempters. Of inconsistent exempters employed after the intervention, 442 (88.9%) of 497 accepted vaccine postintervention compared with 118 (59.6%) of 198 consistent exempters (P < .001). Of all exempters who changed from exemption to acceptance after the intervention, 442 (78.9%) of 560 were inconsistent exempters.

Conclusions:

Critical appraisal of HCP exemption requests promotes influenza vaccine acceptance, and acceptance by inconsistent exempters drives the effect of the intervention. Analysis of changes in annual exemption requests represents a novel objective method for describing those on the spectrum of vaccine hesitancy.

Rapid Deployment of Multiple-Tactics to Address SARS-CoV-2 Vaccine Uptake in Healthcare Employees with a focus on Those Who Identify as Black, Indigenous, and People of Color (BIPOC)

Background

In the third quarter of 2021, government entities enacted vaccine requirements across multiple employment sectors, including healthcare. Experience from previous vaccination campaigns within healthcare emphasize the need to translate community modalities of vaccine outreach and education that partner with Black communities, Indigenous communities, and communities of Color stakeholders to increase vaccine confidence broadly.

Methods

This was an observational feasibility study conducted from August through October 2021 that deployed and measured the effect of a multimodal approach to increasing vaccine uptake in healthcare employees. Vaccine data were acquired through the Center for Disease Control Immunization Information Systems across Oregon and Washington. Rates of complete vaccination before the intervention were compared with rates after as a measure of feasibility of this intervention. These data were subdivided by race/ethnicity, age, gender, and job class. Complete vaccination was defined as completion of a 2-dose mRNA SARS-CoV-2 vaccine series or a 1-dose adenoviral vector SARS-CoV-2 vaccine.

Results

Overall preintervention and postintervention complete vaccination rates were 83.7% and 93.5%, respectively. Of those employees who identified as a certain race, black employees demonstrated the greatest percentage difference increase, 18.5% (preintervention, 72.1%; postintervention, 90.6%), followed by Hispanic employees, 14.1% (preintervention, 79.4%; postintervention, 93.5%), and employees who identify as 2 or more races, 13.9% (preintervention, 78.7%; postintervention, 92.6%)

Conclusions

We found that a multimodal approach to improving vaccination uptake in employees was feasible. For organizations addressing vaccine requirements for their workforce, we recommend a multimodal strategy to increase vaccine confidence and uptake.

Is flu vaccination opt-out feasible? Evidence from vaccination programme implementers and managers in the English National Health Service

BACKGROUND

In 2018/19, English NHS trusts (NHSTs) implemented an 'opt-out' policy for seasonal flu vaccination in frontline healthcare workers (HCWs). HCWs declining the vaccination were asked to sign an opt-out form and provide a reason for their decision. In addition, HCWs working in higher risk hospital environments (e.g. oncology) were asked to inform their manager about their declination decision. The policy aimed to provide greater insight into reasons for vaccination decline and information from HCWs in higher risk areas was intended for use in considering HCW redeployment. This study investigated the feasibility, acceptability, and perceived value of the policy during the 2018/19 flu vaccination season.

METHODS

We conducted semi-structured interviews across 9 NHSTs in England with different levels of HCW flu vaccination uptake in 2017/18. We interviewed 30 vaccination programme implementers and 27 managers.

FINDINGS

The purpose of the policy was poorly understood, and interviewees did not know how data on decliners was being used. Most NHSTs tried to collect the personal details of decliners and, in some instances, these were recorded in Electronic Staff Records and reported to line-managers for action. This created strain on employer-employee relationships, leading to decliners refusing to complete opt-out forms and some vaccinators not implementing the policy. None of the NHSTs had a redeployment policy for decliners, arguing that this was impractical due to strain on staffing levels.

CONCLUSION

A flu-vaccination opt-out approach for HCWs did not appear acceptable in our sampled NHSTs, due to a lack of clear messaging about its purpose and complicated implementation. To promote an opt-out approach effectively, there needs to be clear communication of its purpose, which should be to explore reasons for decline rather than identify and 'push' decliners to vaccinate, so as not to damage staff relationships. NHSTs should involve their workforce in developing flu vaccination approaches.

Attitudes and beliefs of healthcare workers about influenza vaccination

BACKGROUND

Annual influenza vaccination is recommended for all healthcare workers (HCWs) to help reduce the risk of contracting the virus and transmitting it to vulnerable people, especially older adults in residential care facilities. Vaccination uptake among HCWs remains low.

AIM

To investigate HCWs' attitudes towards, and beliefs about, seasonal influenza vaccination in a residential care facility for older adults in the Republic of Ireland.

METHOD

Data were collected using a self-administered questionnaire.

RESULTS

A total of 95 questionnaires were distributed, and 35 (37%) HCWs completed and returned them. During the 2016-17 flu season, 20 (57%) respondents were vaccinated. Primary predictors of vaccination acceptance were the belief that being healthy should not mitigate against requiring the vaccine ( r =0.7, P =0.01), protection of self and family ( r =0.67, P =0.01), protection of patients ( r =0.592, P =0.01) and agreement with mandatory vaccination ( r =0.351, P =0.039). Reasons for vaccination avoidance were misconceptions about the need for vaccination among healthy HCWs (67%), efficacy of the vaccine (60%), lack of trust in the vaccine (47%) and a belief that the vaccine may cause flu (47%).

CONCLUSION

Addressing HCWs' beliefs relating to the personal benefits of vaccination while simultaneously correcting misconceptions may help to increase uptake among those working in residential care settings for older adults.

Randomized Quality Improvement Trial of Opting-In Versus Opting-Out to Increase Influenza Vaccination Rates during Pregnancy

Introduction  Despite strong recommendations, only 40.6% of pregnant women attending two prenatal clinics were vaccinated against influenza during the 2009 pandemic. We tested whether an opting-out approach would improve vaccine uptake. Methods  We conducted a randomized quality improvement (QI) trial to compare opting-out with conventional opting-in consent for influenza immunization. Women age ≥ 18 years attending the University of Texas Health Science Center at Houston (UTHealth) or UT-Medical Branch (UTMB) prenatal clinics during the 2010-2011 influenza season, were eligible. Results  We enrolled 280 women (140 UTHealth, 140 UTMB). Both groups had similar mean age (26.0 ± 5.5 years), mean gestational age (19.4 ± 9.5 weeks), and percent with underlying health conditions (20.7%). Vaccination rates with opting-in and opting-out were similar among all (83 vs. 84%), UTHealth (87 vs. 93%), and UTMB patients (79 vs.76%) ( p  > 0.05). In subsamples of patients assessed, consent strategy did not significantly affect maternal recall of information provided. Conclusion  While prenatal influenza vaccination uptake doubled from the 2009-2010 influenza season, opting-out did not perform better than opting-in, a conclusion opposite that we would have reached had this been a nonconcurrent trial. Vaccination rates dropped posttrial; hence, continued research is needed to increase the prenatal influenza immunizations.

Factors contributing to declination of annual influenza vaccination by healthcare workers caring for cancer patients: An Australian experience

Healthcare workers (HCWs) at an Australian cancer centre were evaluated using a voluntary declination form program to determine factors contributing to declination of annual influenza vaccination. Overall, 1835/2041 HCWs (89.9%) completed a consent or declination form; 1783 were vaccinated and 52 declined. Staff roles with minimal patient contact were significantly associated with lower vaccine uptake (adjusted odds ratio 0.48, 95% confidence interval 0.23-0.99). Reasons for vaccine refusal included personal choice (41%), previous side-effect/s (23.1%), and medical reasons (23.1%). Of these, a large proportion may not be amenable to intervention, and this must be considered in setting threshold targets for future campaigns.

Interventions to increase seasonal influenza vaccine coverage in healthcare workers: A systematic review and meta-regression analysis

Influenza vaccination is recommended for healthcare workers (HCWs), but coverage is often low. We reviewed studies evaluating interventions to increase seasonal influenza vaccination coverage in HCWs, including a meta-regression analysis to quantify the effect of each component. Fourty-six eligible studies were identified. Domains conferring a high risk of bias were identified in most studies. Mandatory vaccination was the most effective intervention component (Risk Ratio of being unvaccinated [RRunvacc] = 0.18, 95% CI: 0.08-0.45), followed by "soft" mandates such as declination statements (RRunvacc = 0.64, 95% CI: 0.45-0.92), increased awareness (RRunvacc = 0.83, 95% CI: 0.71-0.97) and increased access (RRunvacc = 0.88, 95% CI: 0.78-1.00). For incentives the difference was not significant, while for education no effect was observed. Heterogeneity was substantial (τ(2) = 0.083). These results indicate that effective alternatives to mandatory HCWs influenza vaccination do exist, and need to be further explored in future studies.

How to improve influenza vaccine coverage of healthcare personnel

Influenza causes substantial morbidity and mortality worldwide each year. Healthcare-associated influenza is a frequent event. Health care personnel (HCP) may be the source for infecting patients and may propagate nosocomial outbreaks. All HCP should receive a dose of influenza vaccine each year to protect themselves and others. This commentary will discuss the study recently published in the IJHPR by Nutman and Yoeli which assessed the beliefs and attitudes of HCP in an Israel hospital regarding influenza and the influenza vaccine. Unfortunately, as noted by Nutman and Yoeli in this issue many HCP in Israel choose not to receive influenza immunization and many harbor misconceptions regarding their risk for influenza as well as the benefits of influenza vaccine. We also discuss proven methods to increase acceptance by HCP for receiving an annual influenza vaccine.

The role of healthcare provider attitudes in increasing willingness to accept seasonal influenza vaccine policy changes

BACKGROUND

This research explored the role of attitudes in acceptance of organizational change initiatives.

METHODS

A survey assessed factors associated with health care provider (HCP) likelihood to accept seasonal influenza vaccine policy changes. We evaluated the impact of knowledge and individual attitudes on this outcome measure.

RESULTS

Knowledge of seasonal influenza vaccine and influenza recommendations was a significant predictor of HCP's attitudes toward vaccine at the individual (p<0.001), organizational (p<0.05), and legislative level (p<0.05). Mixed results were obtained when investigating the impact of knowledge on actual willingness to accept vaccine, suggesting that knowledge was only a significant predictor at the organizational (p<0.05) and legislative levels (p<0.05). Attitudes fully mediated the impact of knowledge at both the organizational and legislative levels.

INTERPRETATION

Knowledge of seasonal influenza and vaccine recommendations is an important, but insufficient predictor of willingness to accept policy change.

Vaccine hesitancy and healthcare providers

While most people vaccinate according to the recommended schedule, this success is challenged by individuals and groups who delay or refuse vaccines. The aim of this article is to review studies on vaccine hesitancy among healthcare providers (HCPs), and the influences of their own vaccine confidence and vaccination behaviour on their vaccination recommendations to others. The search strategy was developed in Medline and then adapted across several multidisciplinary mainstream databases including Embase Classic & Embase, and PschInfo. All foreign language articles were included if the abstract was available in English. A total of 185 articles were included in the literature review. 66% studied the vaccine hesitancy among HCPs, 17% analysed concerns, attitudes and/or behaviour of HCPs towards vaccinating others, and 9% were about evaluating intervention(s). Overall, knowledge about particular vaccines, their efficacy and safety, helped to build HCPs own confidence in vaccines and their willingness to recommend vaccines to others. The importance of societal endorsement and support from colleagues was also reported. In the face of emerging vaccine hesitancy, HCPs still remain the most trusted advisor and influencer of vaccination decisions. The capacity and confidence of HCPs, though, are stretched as they are faced with time constraints, increased workload and limited resources, and often have inadequate information or training support to address parents' questions. Overall, HCPs need more support to manage the quickly evolving vaccine environment as well as changing public, especially those who are reluctant or refuse vaccination. Some recommended strategies included strengthening trust between HCPs, health authorities and policymakers, through more shared involvement in the establishment of vaccine recommendations.

Association of increased influenza vaccination in health care workers with a reduction in nosocomial influenza infections in cancer patients

BACKGROUND

Vaccination of health care workers (HCWs) remains a key strategy to reduce the burden of influenza infections in cancer patients.

METHODS

In this 8-year study, we evaluated the effect of a multifaceted approach, including a mandatory influenza vaccination program, on HCW vaccination rates and its effect on nosocomial influenza infections in cancer patients.

RESULTS

The influenza vaccination rate of all employees significantly increased from 56% (8,762/15,693) in 2006-2007 to 94% (17,927/19,114) in 2013-2014 (P < .0001). The 2009 mandatory participation program increased HCW vaccination rates in the targeted groups (P < .0001), and the addition of an institutional policy in 2012 requiring influenza vaccination or surgical mask use with each patient contact further increased vaccination rates by 10%-18% for all groups in 1 year. The proportion of nosocomial influenza infections significantly decreased (P = .045) during the study period and was significantly associated with increased HCW vaccination rates in the nursing staff (P = .043) and in personnel working in high-risk areas (P = .0497).

CONCLUSIONS

Multifaceted influenza vaccination programs supported by institutional policy effectively increased HCW vaccination rates. Increased HCW vaccination rates were associated with a reduction in the proportion of nosocomial influenza infections in immunocompromised cancer patients.

Outcomes, Approaches, and Challenges to Developing and Passing a Countywide Mandatory Vaccination Policy: St. Louis County's Experience with Hepatitis A Vaccine for Food Service Personnel

In the early 1990s, St. Louis County had multiple foodservice worker-related hepatitis A outbreaks uncontrolled by standard outbreak interventions. Restaurant interest groups and the general public applied political pressure to local public health officials for more stringent interventions, including a mandatory vaccination policy. Local health departments can enact mandatory vaccination policies, but this has rarely been done. The study objectives were to describe the approach used to pass a mandatory vaccination policy at the local jurisdiction level and illustrate the outcome from this ordinance 15 years later. A case study design was used. In-depth, semi-structured interviews using guided questions were conducted in spring, 2015, with six key informants who had direct knowledge of the mandatory vaccination policy process. Meeting minutes and/or reports were also analyzed. A Poisson distribution analysis was used to calculate the rate of outbreaks before and after mandatory vaccination policy implementation. The policy appears to have reduced the number of hepatitis A outbreaks, lowering the morbidity and economic burden in St. Louis County. The lessons learned by local public health officials in passing a mandatory hepatitis A vaccination policy are important and relevant in today's environment. The experience and lessons learned may assist other local health departments when faced with the potential need for mandatory policies for any vaccine preventable disease.

Acceptance of intradermal inactivated influenza vaccines among hospital staff following 2 seasonal vaccination campaigns

After a Canadian hospital's official influenza vaccination campaign concluded in the 2011-2012 and 2012-2013 influenza seasons, study nurses provided additional vaccination mobile cart hours and the added choice of an intradermal injection. An additional 2.1% of staff in the first and 1.4% in the second season were vaccinated during the study with 90-99% preferring the intradermal injection or having no preference. All 13 staff who attempted self-injection with the intradermal vaccine in 2012-2013 were successful on their first attempt. Offering alternatives to intramuscular vaccines may increase rates of vaccination.

Sustained low influenza vaccination in health care workers after H1N1 pandemic: a cross sectional study in an Italian health care setting for at-risk patients

Background

Despite consistent recommendations by all Public Health Authorities in support of annual influenza vaccination for at-risk categories, there is still a low uptake of influenza vaccine in these groups including health care workers (HCWs). Aim of this observational two-phase study was to estimate the immunization rates for influenza in four subsequent seasons and for pandemic H1N1 influenza in HCWs of a University Hospital, and to investigate its distribution pattern and the main determinants of immunization. Phase 1 data collection was performed in 2009–2010, during the peak of H1N1 pandemic. Phase 2 data collection, aimed to investigate seasonal influenza vaccination coverage in the three seasons after pandemic, was performed in 2012–2013.

Methods

The overall H1N1 vaccination rate was derived by the Hospital immunization registry. In 2010, the personnel of three Departments (Infectious Diseases, Pediatrics and Gynecology/Obstetrics) completed a survey on influenza. A second-phase analysis was performed in 2012 to investigate influenza vaccination coverage in three consecutive seasons.

Results

The first-phase survey showed a low coverage for influenza in all categories (17 %), with the lowest rate in nurses (8.1 %). A total of 37 % of health care workers received H1N1 vaccine, with the highest rate among physicians and the lowest in nurses. H1N1 vaccination was closely related to the Department, being higher in the Department of Infectious Diseases (53.7 %) and Pediatrics (42.4 %) than in Gynecology/Obstetrics (8.3 %). The second-phase survey showed the lowest rate of influenza vaccination in 2012/13 season. The main reasons for not being vaccinated were “Unsure of the efficacy of vaccine” and “Feel not at-risk of getting influenza or its complications”. Despite recommendations, influenza vaccine uptake remains poor.

Conclusion

Immunization is largely perceived as a personal protection rather than a measure needed to prevent disease spreading to at-risk patients. Compulsory vaccination against influenza should be considered as a possible strategy, at least in health institutions where at-risk patients are admitted.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-015-1090-x) contains supplementary material, which is available to authorized users.

Implementing a declination form programme to improve influenza vaccine uptake by staff in Department of Veterans Affairs spinal cord injury centres: a pilot study

BACKGROUND

Individuals with spinal cord injuries and disorders are at high risk for respiratory and influenza-related complications after developing influenza. These individuals often have frequent contact with the healthcare system. Vaccination rates in healthcare workers at Department of Veterans Affairs (VA) spinal cord injury (SCI) centres have been approximately 50% for several years. Efforts are needed to increase vaccination uptake among SCI HCWs. Declination form programmes (DFPs) in combination with other strategies have resulted in significant increases in influenza vaccination uptake in HCWs.

AIM

Use of external and internal facilitation including local teams and consensus processes to pilot a DFP in two VA SCI centres and evaluate factors influencing implementation.

METHODS

Implementation meetings and a consensus-building process with leadership and implementation team members were conducted, along with semi-structured post-implementation interviews with members of each implementation team (N = 7).

FINDINGS

The DFP was well accepted and easy to use. Leadership was a key facilitator for DFP implementation. Barriers included difficulty communicating with HCWs working during early/late shifts. Participation was 100% at Site 1 and 48% at Site 2.

CONCLUSION

Use of local teams and consensus to identify strategies to implement a DFP is feasible and effective for achieving moderate-to-high levels of participation in the programme.

Healthcare worker influenza declination form program

BACKGROUND

Health care worker (HCW) vaccination rates have been low for many years (approximately 50%). Our goal was to implement an influenza declination form program (DFP) to assess feasibility, participation, HCW vaccination, and costs.

METHODS

This was a prospective interventional pilot study using mixed methods to evaluate the DFP implementation processes and outcomes. We conducted a formative evaluation and interviews; data were transcribed and coded into themes. Secondary outcomes included self-reported HCW influenza vaccine uptake (pre-/postsurvey) and program costs; data were evaluated using descriptive and bivariate analyses.

RESULTS

The DFP was compatible with ongoing strategies and unit culture. Barriers included multiple hospital shifts and competing demands. Facilitators included complementary ongoing strategies and leadership engagement. HCW vaccination rates were higher post- versus preimplementation (77.4% vs 53.5%, P =.01). To implement the DFP at site 1, using a mobile flu cart, 100% of declination forms were completed in 42.5 staff hours over <2 months. At site 2, using a vaccination table on all staff meeting days, 49% of forms were completed in 26.5 staff hours over 4.5 months. Average cost of staff time was $2,093 per site.

CONCLUSION

DFP implementation required limited resources and resulted in increased HCW influenza vaccine rates; this may have positive clinical implications for influenza infection control/prevention.

Evaluation of the impact of the 2012 Rhode Island health care worker influenza vaccination regulations: implementation process and vaccination coverage

CONTEXT

In October 2012, the Rhode Island Department of Health (HEALTH) amended its health care worker (HCW) vaccination regulations to require all HCWs to receive annual influenza vaccination or wear a surgical mask during direct patient contact when influenza is widespread. Unvaccinated HCWs failing to wear a mask are subject to a fine and disciplinary action.

OBJECTIVE

To describe the implementation of the 2012 Rhode Island HCW influenza vaccination regulations and examine their impact on vaccination coverage.

DESIGN

Two data sources were used: (1) a survey of all health care facilities subject to the HCW regulations and (2) HCW influenza vaccination coverage data reported to HEALTH by health care facilities. Descriptive statistics and paired t tests were performed using SAS Release 9.2.

SETTING AND PARTICIPANTS

For the 2012-2013 influenza season, 271 inpatient and outpatient health care facilities in Rhode Island were subject to the HCW regulations.

MAIN OUTCOME MEASURE

Increase in HCW influenza vaccination coverage.

RESULTS

Of the 271 facilities, 117 facilities completed the survey (43.2%) and 160 facilities reported vaccination data to HEALTH (59.0%). Between the 2011-2012 and 2012-2013 influenza seasons, the proportion of facilities having a masking policy, as required by the revised regulations, increased from 9.4% to 94.0% (P < .001). However, the proportion of facilities implementing Advisory Committee on Immunization Practices-recommended strategies to promote HCW influenza vaccination did not increase. The majority of facilities perceived benefits to collecting HCW influenza vaccination data, including strengthening infection prevention efforts (83.2%) and improving patient and coworker safety (75.2%). Concurrent with the new regulations, influenza vaccination coverage among employee HCWs in Rhode Island increased from 69.7% in the 2011-2012 influenza season to 87.2% in the 2012-2013 season.

CONCLUSION

Rhode Island's experience demonstrates that statewide HCW influenza vaccination requirements incorporating mask wearing and moderate penalties for noncompliance can be effective in improving influenza vaccination coverage among HCWs.

Strategies for addressing vaccine hesitancy - A systematic review

The purpose of this systematic review is to identify, describe and assess the potential effectiveness of strategies to respond to issues of vaccine hesitancy that have been implemented and evaluated across diverse global contexts.

METHODS

A systematic review of peer reviewed (January 2007-October 2013) and grey literature (up to October 2013) was conducted using a broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy concerning vaccines. This search strategy was applied and adapted across several databases and organizational websites. Descriptive analyses were undertaken for 166 (peer reviewed) and 15 (grey literature) evaluation studies. In addition, the quality of evidence relating to a series of PICO (population, intervention, comparison/control, outcomes) questions defined by the SAGE Working Group on Vaccine Hesitancy (WG) was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria; data were analyzed using Review Manager.

RESULTS

Across the literature, few strategies to address vaccine hesitancy were found to have been evaluated for impact on either vaccination uptake and/or changes in knowledge, awareness or attitude (only 14% of peer reviewed and 25% of grey literature). The majority of evaluation studies were based in the Americas and primarily focused on influenza, human papillomavirus (HPV) and childhood vaccines. In low- and middle-income regions, the focus was on diphtheria, tetanus and pertussis, and polio. Across all regions, most interventions were multi-component and the majority of strategies focused on raising knowledge and awareness. Thirteen relevant studies were used for the GRADE assessment that indicated evidence of moderate quality for the use of social mobilization, mass media, communication tool-based training for health-care workers, non-financial incentives and reminder/recall-based interventions. Overall, our results showed that multicomponent and dialogue-based interventions were most effective. However, given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context.

An effective strategy for influenza vaccination of healthcare workers in Australia: experience at a large health service without a mandatory policy

Background

Annual influenza vaccination of healthcare workers (HCWs) is recommended in Australia, but uptake in healthcare facilities has historically been low (approximately 50%). The objective of this study was to develop and implement a dedicated campaign to improve uptake of staff influenza annual vaccination at a large Australian health service.

Methods

A quality improvement program was developed at Alfred Health, a tertiary metropolitan health service spanning 3 campuses. Pre-campaign evaluation was performed by questionnaire in 2013 to plan a multimodal vaccination strategy. Reasons for and against vaccination were captured. A campaign targeting clinical and non-clinical healthcare workers was then implemented between March 31 and July 31 2014. Proportional uptake of influenza vaccination was determined by campus and staff category.

Results

Pre-campaign questionnaire responses were received from 1328/6879 HCWs (response rate 20.4%), of which 76% were vaccinated. Common beliefs held by unvaccinated staff included vaccine ineffectiveness (37.1%), that vaccination makes staff unwell (21.0%), or that vaccination is not required because staff are at low risk for acquiring influenza (20.2%). In 2014, 6009/7480 (80.3%) staff were vaccinated, with significant improvement in uptake across all campuses and amongst nursing, medical and allied health staff categories from 2013 to 2014 (p < 0.0001).

Conclusions

A non-mandatory multimodal strategy utilising social marketing and a customised staff database was successful in increasing influenza vaccination uptake by all staff categories. The sustainability of dedicated campaigns must be evaluated.

Factorial Design for Improving Influenza Vaccination Among Employees of a Large Health System

Objective.

As healthcare personnel (HCP) influenza vaccination becomes a quality indicator for healthcare facilities, effective inter¬ventions are needed. This study was designed to test a factorial design to improve HCP vaccination rates.

Design.

A before-after trial with education, publicity, and free and easily accessible influenza vaccines used a factorial design to determine the effect of mobile vaccination carts and incentives on vaccination rates of HCP, who were divided into groups on the basis of their level of patient contact (ie, business and/or administrative role, indirect patient contact, and direct patient contact).

Setting.

Eleven acute care facilities in a large health system.

Participants.

More than 26,000 nonphysician employees.

Results.

Influenza vaccination rates increased significantly in most facilities and increased system-wide from 32.4% to 39.6% (P < .001). In the baseline year, business unit employee vaccination rates were significantly higher than among HCP with patient contact; rates did not differ significantly across groups in the intervention year. In logistic regression that accounted for demographic characteristics, intervention year, and other factors, the use of incentives and/or mobile carts that provided access to vaccine at the work unit significantly increased the likelihood of vaccination among HCP with direct and indirect patient contact, compared with control sites.

Conclusions.

Interventions to improve vaccination rates are differentially effective among HCP with varying levels of patient contact. Mobile carts appear to remove access barriers, whereas incentives may motivate HCP to be vaccinated. Education and publicity may be sufficient for workers in business or administrative positions. Interventions tailored by worker type are likely to be most successful for improving HCP vaccination rates.

Web-Based Electronic Health Records Improve Data Completeness and Reduce Medical Discrepancies in Employee Vaccination Programs

A Web-based electronic health record (EHR) system was compared with traditional paper-based documentation and vaccination tracking during the 2009 H1N1 influenza pandemic. In a cohort of 8,411 healthcare network employees, EHRs improved completeness of self-reported contraindication data and reduced medical discrepancies. Vaccination program quality and accuracy are enhanced by EHRs.

Infect Control Hosp Epidemiol 2012;33(1):84-86

Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel

Executive Summary

This document serves as an update and companion piece to the 2005 Society for Healthcare Epidemiology of America (SHEA) Position Paper entitled “Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages.” In large part, the discussion about the rationale for influenza vaccination of healthcare personnel (HCP), the strategies designed to improve influenza vaccination rates in this population, and the recommendations made in the 2005 paper still stand. This position paper notes new evidence released since publication of the 2005 paper and strengthens SHEA's position on the importance of influenza vaccination of HCP. This document does not discuss vaccine allocation during times of vaccine shortage, because the 2005 SHEA Position Paper still serves as the Society's official statement on that issue.

A Successful Strategy for Increasing the Influenza Vaccination Rate of Healthcare Workers without a Mandatory Policy Outside of the United States: A Multifaceted Intervention in a Japanese Tertiary Care Center

Objective.

Although mandatory vaccination programs have been effective in improving the vaccination rate among healthcare workers, implementing this type of program can be challenging because of varied reasons for vaccine refusal. The purpose of our study is to measure improvement in the influenza vaccination rate from a multifaceted intervention at a Japanese tertiary care center where implementing a mandatory vaccination program is difficult.

Design.

Before-and-after trial.

Participants and Setting.

Healthcare workers at a 550-bed, tertiary care, academic medical center in Sapporo, Japan.

Interventions.

We performed a multifaceted intervention including (1) use of a declination form, (2) free vaccination, (3) hospital-wide announcements during the vaccination period, (4) prospective audit and real-time telephone interview for healthcare workers who did not receive the vaccine, (5) medical interview with the hospital executive for noncompliant (no vaccine, no declination form) healthcare workers during the vaccination period, and (6) mandatory submission of a vaccination document if vaccinated outside of the study institution.

Results.

With the new multifaceted intervention, the vaccination rate in the 2012-2013 season increased substantially, up to 97%. This rate is similar to that reported in studies with a mandatory vaccination program. Improved vaccination acceptance, particularly among physicians, likely contributed to the overall increase in the vaccination rate reported in the study.

Conclusions.

Implementation of comprehensive strategies with strong leadership can lead to substantial improvements in vaccine uptake among healthcare workers even without a mandatory vaccination policy. The concept is especially important for institutions where implementing mandatory vaccination programs is challenging.

Association between health care workers' knowledge of influenza vaccine and vaccine uptake

Immunization is the most effective measure available to prevent influenza and its complications, and health care workers (HCWs) play a pivotal role. We conducted a cross-sectional survey study to determine HCWs knowledge and opinions regarding influenza vaccine and its acceptance at our institution. The most important reason for vaccine uptake was because it required formal declination (33%); physicians were more likely to be vaccinated because of patient care, whereas nurses were more likely to be vaccinated because it required formal declination.

Correlates of improved influenza vaccination of healthcare personnel: a survey of hospitals in Louisiana

OBJECTIVE

To describe practices for influenza vaccination of healthcare personnel (HCP) with emphasis on correlates of increased vaccination rates.

DESIGN

Survey.

PARTICIPANTS

Volunteer sample of hospitals in Louisiana.

METHODS

All hospitals in Louisiana were invited to participate. A 17-item questionnaire inquired about the hospital type, patients served, characteristics of the vaccination campaign, and the resulting vaccination rate.

RESULTS

Of 254 hospitals, 153 (60%) participated and were included in the 124 responses that were received. Most programs (64%) required that HCP either receive the vaccine or sign a declination form, and the rest were exclusively voluntary (36%); no program made vaccination a condition of employment. The median vaccination rate was 67%, and the vaccination rate was higher among hospitals that were accredited by the Joint Commission; provided acute care; served children, pregnant women, oncology patients, or intensive care unit patients; required a signed declination form; or imposed consequences for unvaccinated HCP (the most common of which was to require that a mask be worn on patient contact). Hospitals that provided free vaccine, made vaccine widely available, advertised the program extensively, required a declination form, and imposed consequences had the highest vaccination rates (median, 86%; range, 81%-91%).

CONCLUSIONS

The rate of influenza vaccination of HCP remains low among the hospitals surveyed. Recommended practices may not be enough to reach 90% vaccination rates unless a signed declination requirement and consequences are implemented. Wearing a mask is a strong consequence. Demanding influenza vaccination as a condition of employment was not reported as a practice by the participating hospitals.

Reliability and validity of a standardized measure of influenza vaccination coverage among healthcare personnel

OBJECTIVE

To evaluate the reliability and validity of a standardized measure of healthcare personnel (HCP) influenza vaccination.

SETTING

Acute care hospitals, long-term care facilities, ambulatory surgery centers, physician practices, and dialysis centers from 3 US jurisdictions.

PARTICIPANTS

Staff from 96 healthcare facilities randomly sampled from 234 facilities that completed pilot testing to assess the feasibility of the measure.

METHODS

Reliability was assessed by comparing agreement between facility staff and project staff on the classification of HCP numerator (vaccinated at facility, vaccinated elsewhere, contraindicated, declined) and denominator (employees, credentialed nonemployees, other nonemployees) categories. To assess validity, facility staff completed a series of case studies to evaluate how closely classification of HCP groups aligned with the measure's specifications. In a modified Delphi process, experts rated face validity of the proposed measure elements on a Likert-type scale.

RESULTS

Percent agreement was high for HCP vaccinated at the facility (99%) and elsewhere (95%) and was lower for HCP who declined vaccination (64%) or were medically contraindicated (64%). While agreement was high (more than 90%) for all denominator categories, many facilities' staff excluded nonemployees for whom numerator and denominator status was difficult to determine. Validity was lowest for credentialed and other nonemployees.

CONCLUSIONS

The standardized measure of HCP influenza vaccination yields reproducible results for employees vaccinated at the facility and elsewhere. Adhering to true medical contraindications and tracking declinations should improve reliability. Difficulties in establishing denominators and determining vaccination status for credentialed and other nonemployees challenged the measure's validity and prompted revision to include a more limited group of nonemployees.

Review: interventions to increase influenza vaccination among healthcare workers in hospitals

Please cite this paper as: Hollmeyer et al. (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza and Other Respiratory Viruses 7(4), 604–621.

Annual influenza vaccination rates among hospital healthcare workers (HCW) are almost universally low despite recommendations from WHO and public health authorities in many countries. To assist in the development of successful vaccination programmes, we reviewed studies where interventions aimed to increase the uptake of influenza vaccination among hospital HCW. We searched PUBMED from 1990 up to December 2011 for publications with predetermined search strategies and of pre‐defined criteria for inclusion or exclusion. We evaluated a large number of ‘intervention programmes’ each employing one or more ‘intervention components’ or strategies, such as easy access to vaccine or educational activities, with the goal to raise influenza vaccine uptake rates in hospital HCW during one influenza season. Included studies reported results of intervention programmes and compared the uptake with the season prior to the intervention (historical control) or to another intervention programme within the same season that started from the same set of baseline activities. Twenty‐five studies performed in eight countries met our selection criteria and described 45 distinct intervention programmes. Most studies used their own facility as historical control and evaluated only one season. The following elements were used in intervention programmes that increased vaccine uptake: provision of free vaccine, easy access to the vaccine (e.g. through mobile carts or on‐site vaccination), knowledge and behaviour modification through educational activities and/or reminders and/or incentives, management or organizational changes, such as the assignment of personnel dedicated to the intervention programme, long‐term implementation of the strategy, requiring active declination and mandatory immunization policies. The number of these components applied appeared to be proportional to the increase in uptake. If influenza uptake in hospital HCW is to be increased on sustained basis, hospital managers need to be committed to conduct a well‐designed long‐term intervention programme that includes a variety of co‐ordinated managerial and organizational elements.

Protecting patients, protecting healthcare workers: a review of the role of influenza vaccination

AIM

Many health authorities recommend routine influenza vaccination for healthcare workers (HCWs), and during the 2009 A (H1N1) pandemic, the World Health Organization (WHO) recommended immunization of all HCWs worldwide. As this remains an important area of policy debate, this paper examines the case for vaccination, the role of local guidelines, barriers to immunization and initiatives to increase uptake.

BACKGROUND

Seasonal influenza is a major threat to public health, causing up to 1 million deaths annually. Extensive evidence supports the vaccination of priority groups, including HCWs. Immunization protects HCWs themselves, and their vulnerable patients from nosocomial influenza infections. In addition, influenza can disrupt health services and impact healthcare organizations financially. Immunization can reduce staff absences, offer cost savings and provide economic benefits.

METHODS

This paper reviews official immunization recommendations and HCW vaccination studies, including a recent International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) survey of 26 countries from each region of the world.

RESULTS

HCW immunization is widely recommended and supported by the WHO. In the IFPMA study, 88% of countries recommended HCW vaccination, and 61% supported this financially (with no correlation to country development status). Overall, coverage can be improved, and research shows that uptake may be impacted by lack of conveniently available vaccines and misconceptions regarding vaccine safety/efficacy and influenza risk.

CONCLUSIONS

Many countries recommend HCW vaccination against influenza. In recent years, there has been an increased uptake rate among HCWs in some countries, but not in others. Several initiatives can increase coverage, including education, easy access to free vaccines and the use of formal declination forms. The case for HCW vaccination is clear, and in an effort to further accelerate uptake as a patient safety measure, an increasing number of healthcare organizations, particularly in the USA, are implementing mandatory immunization policies, similar to other obligatory hygiene measures. However, it would be desirable if similar high vaccination uptake rates could be achieved through voluntary procedures.

Development and testing of an instrument to assess nurses' knowledge, risk perception, health beliefs and behaviours related to influenza vaccination

AIMS AND OBJECTIVES

To develop an instrument to measure nurses' knowledge, risk perception and health beliefs towards influenza and influenza vaccination and their vaccination behaviours and evaluate its construct validity and internal consistency reliability.

BACKGROUND

Although instruments to assess predictors of nurses' vaccination behaviours have been developed, their validity and reliability have not been reported.

DESIGN

Instrument development and initial validity and reliability testing.

METHODS

The instrument was developed drawing on a literature review and expert consultation and was refined through pilot work. A cross-sectional survey using a revised version of the instrument was conducted among a convenience sample of 520 registered nurses (response rate 77.4%). Cronbach's alpha coefficient was calculated to determine internal consistency of the sub-scale in the instrument. Principal components analysis with varimax rotation was carried out to evaluate the instrument's construct validity and examine its internal structure.

RESULTS

Cronbach's alpha coefficients for the three newly developed scales ranged from 0.70-0.76. Principal components analysis produced a good fit and confirmed the internal design of the instrument. In the seasonal influenza knowledge sub-scale four factors explained 44.8% of the total variance; in the H1N1 knowledge sub-scale two factors explained 44.7% of the total variance. Three factors in the risk perception scale contributed 50.5% of the total variance and two factors in the vaccination behaviours scale contributed 62.1% of the total variance.

CONCLUSIONS

An instrument has been developed to assess nurses' knowledge, risk perception and health beliefs towards influenza and influenza vaccination and their vaccination behaviours. The instrument was valid and reliable for the setting where it was used.

RELEVANCE TO CLINICAL PRACTICE

This instrument could be used to assess nurses' knowledge, risk perception, health beliefs towards influenza and influenza vaccination and their vaccination behaviours. The three newly developed scales could also be used independently to measure variables influencing nurses' vaccination practices.

H1N1 influenza vaccine compliance among hospital- and non-hospital-based healthcare personnel

BACKGROUND

The 2009 pandemic H1N1 influenza vaccine had lower uptake compared to seasonal influenza vaccine, and most studies examining uptake of H1N1 vaccine focused on hospital-based healthcare personnel (HCP). Determinants of H1N1 vaccine uptake among HCP in all work settings need to be identified so that interventions can be developed for use in encouraging uptake of future pandemic or emerging infectious disease vaccines.

OBJECTIVE

To identify factors influencing nonhospital HCP H1N1 influenza vaccine compliance.

DESIGN AND SETTING

An H1N1 influenza vaccine compliance questionnaire was administered to HCP working in myriad healthcare settings in March-June 2011.

METHODS

Surveys were used to assess H1N1 influenza vaccine compliance and examine factors that predicted H1N1 influenza vaccine uptake.

RESULTS

In all, 3,188 HCP completed the survey. Hospital-based HCP had higher compliance than did non-hospital-based personnel (Χ2 = 142.2, P < .001). In logistic regression stratified by hospital setting versus nonhospital setting, determinants of H1N1 vaccination among non-hospital-based HCP included extent to which H1N1 vaccination was mandated or encouraged, perceived importance of vaccination, access to no-cost vaccine provided on-site, no fear of vaccine side effects, and trust in public health officials when they say that the influenza vaccine is safe. Determinants of hospital-based HCP H1N1 vaccine compliance included having a mandatory vaccination policy, perceived importance of vaccination, no fear of vaccine side effects, free vaccine, perceived seriousness of H1N1 influenza, and trust in public health officials.

CONCLUSIONS

Non-hospital-based HCP versus hospital-based HCP reasons for H1N1 vaccine uptake differed. Targeted interventions are needed to increase compliance with pandemic-related vaccines.

Public health worker attitudes and beliefs concerning 2009 H1N1 and seasonal influenza vaccines

In this study examining public health workers' 2009 H1N1 and seasonal influenza vaccination uptake, a survey was conducted to assess flu vaccine acceptance, as well as behaviors and beliefs regarding acceptance, among public health workers in southeastern Tennessee. Factors found to be significantly associated with acceptance of the 2009 H1N1 vaccine were direct patient care, previous flu vaccination, vaccine safety concerns, and receipt of seasonal flu vaccine.

Institutional requirements for influenza vaccination of healthcare personnel: results from a nationally representative survey of acute care hospitals--United States, 2011

BACKGROUND

Many health professional organizations now endorse influenza vaccination as a condition of employment in healthcare settings. Our objective was to describe institutional requirements for influenza vaccination of healthcare personnel (HCP) among US hospitals during the 2010-2011 influenza season.

METHODS

A survey was mailed in 2011 to a nationally representative sample of 998 acute care hospitals. An institutional requirement was defined as "a policy that requires HCP to receive or decline influenza vaccination, with or without consequences for vaccine refusal." A weighted analysis included univariate analyses and logistic regression.

RESULTS

Of responding hospitals (n = 808; 81.0%), 440 (55.6%) reported institutional requirements for influenza vaccination. Although employees were uniformly subject to requirements, nonemployees often were not. The proportion of requirements with consequences for vaccine refusal was 44.4% (n = 194); where consequences were imposed, nonmedical exemptions were often granted (69.3%). Wearing a mask was the most common consequence (74.2% of 194 requirements); by contrast, 29 hospitals (14.4%) terminated unvaccinated HCP. After adjustment for demographic factors, the following characteristics remained significantly associated with requirements: location in a state requiring HCP to receive or decline influenza vaccine, caring for inpatients that are potentially vulnerable to influenza, use of ≥9 Advisory Committee on Immunization Practices-recommended, evidence-based influenza vaccination campaign strategies, and for-profit ownership.

CONCLUSIONS

Influenza vaccination requirements were prevalent among hospitals of varying size and location. However, few policies were as stringent or as comprehensive as those endorsed by health professional organizations. Because influenza vaccination requirements are a viable alternative for hospitals unable to achieve high coverage through voluntary policies, there is still substantial room for improvement.

Seasonal influenza vaccine compliance among hospital-based and nonhospital-based healthcare workers

BACKGROUND

Influenza vaccination among nonhospital healthcare workers (HCWs) is imperative, but only limited data are available for factors affecting their compliance.

OBJECTIVE

To examine the factors influencing influenza vaccine compliance among hospital and nonhospital HCWs. Design and Setting. A vaccine compliance questionnaire was administered to HCWs working in myriad healthcare settings in March-June 2011.

METHODS

Online and paper surveys were used to assess compliance with the 2010/2011, 2009/2010, and H1N1 influenza vaccines and to examine factors that predicted the uptake of the 2010/2011 seasonal influenza vaccine.

RESULTS

In all, 3,188 HCWs completed the survey; half of these ([Formula: see text]) reported no hospital work time. Compliance rates for all 3 vaccines were significantly higher ([Formula: see text]) among hospital versus nonhospital HCWs. In logistic regression stratified by hospital versus nonhospital setting, and when controlling for demographics and past behavior, the determinants of vaccination against the 2010/2011 seasonal influenza among nonhospital-based HCWs included having a mandatory vaccination policy, perceived importance, no fear of vaccine adverse effects, free and on-site access, and perceived susceptibility to influenza. Determinants of hospital-based HCW vaccine compliance included having a mandatory vaccination policy, belief that HCWs should be vaccinated every year, occupational health encouragement, perceived importance of vaccination, on-site access, and no fear of vaccine adverse effects. The strongest predictor of compliance for both worker groups was existence of a mandatory vaccination policy.

CONCLUSIONS

The reasons for vaccine uptake among nonhospital-based versus hospital-based HCWs differed. Targeted interventions should be aimed at workers in these settings to increase their vaccine compliance, including implementing a mandatory vaccination policy.