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.

Evidence base for yearly respiratory virus vaccines: Current status and proposed improved strategies

Annual vaccination is widely recommended for influenza and SARS-CoV-2. In this essay, we analyse and question the prevailing policymaking approach to these respiratory virus vaccines, especially in the United States. Every year, licensed influenza vaccines are reformulated to include specific strains expected to dominate in the season ahead. Updated vaccines are rapidly manufactured and approved without further regulatory requirement of clinical data. Novel vaccines (i.e. new products) typically undergo clinical trials, though generally powered for clinically unimportant outcomes (e.g. lab-confirmed infections, regardless of symptomatology or antibody levels). Eventually, the current and future efficacy of influenza and COVID-19 vaccines against hospitalization or death carries considerable uncertainty. The emergence of highly transmissible SARS-CoV-2 variants and waning vaccine-induced immunity led to plummeting vaccine effectiveness, at least against symptomatic infection, and booster doses have since been widely recommended. No further randomized trials were performed for clinically important outcomes for licensed updated boosters. In both cases, annual vaccine effectiveness estimates are generated by observational research, but observational studies are particularly susceptible to confounding and bias. Well-conducted experimental studies, particularly randomized trials, are necessary to address persistent uncertainties about influenza and COVID-19 vaccines. We propose a new research framework which would render results relevant to the current or future respiratory viral seasons. We demonstrate that experimental studies are feasible by adopting a more pragmatic approach and provide strategies on how to do so. When it comes to implementing policies that seriously impact people's lives, require substantial public resources and/or rely on widespread public acceptance, high evidence standards are desirable.

Knowledge and attitudes of healthcare workers about influenza vaccination

BACKGROUND

Influenza infection is a highly contagious viral disease. It may cause several nosocomial outbreaks. This study aimed to evaluate the knowledge and attitudes of healthcare workers (HCWs) about influenza vaccination and to identify factors associated with the uptake of influenza vaccination.

METHODS

We conducted a cross-sectional study over 5 months between November 2021 and March 2022. Data was collected using an anonymous self-administered questionnaire. We included all HCWs at Taher Sfar University Hospital who were willing to participate in the study.

RESULTS

A total of 395 HCWs were included. They were mainly women (78.7%) with an average age of 27 years. The medical personnel was the largest group (67.8%). Most respondents considered the vaccination to be optional and knew that it should be renewed every year, but 97.5% of them judged the efficacy of the vaccine to be low. The influenza vaccination uptake was only 20.2%. The main reasons for accepting vaccination were to protect patients and families. However, misconceptions about the severity and the risk of influenza and the belief that barrier measures were sufficient to prevent infection were the main causes of avoiding vaccination. The factors associated with adherence to vaccination were being a medical professional, old age, longer professional experience, and considering vaccination to be mandatory for HCWs.

CONCLUSION

Our study showed a low adherence to influenza vaccination with misconceptions about vaccine efficacy and safety. More efforts are needed to improve the knowledge of HCW about the vaccine and boost the adherence rates.

COVID-19 vaccine perspectives and uptake among university students three years into the pandemic

BACKGROUND

University students have been uniquely impacted by the COVID-19 pandemic for the past three years (2020-2023). Understanding their COVID-19 perspectives, beliefs, and vaccine uptake may help to improve future vaccine initiatives and education.

METHODS

A cross sectional, confidential, online survey was conducted at four universities in Pennsylvania in spring 2023 to assess undergraduate, graduate, and professional students' perspectives regarding their knowledge of COVID-19 vaccines, importance of COVID-19 vaccines and mandates, number of doses of COVID-19 vaccine received including the recent BA.4/BA.5 bivalent booster, where they were vaccinated, receipt of influenza vaccine, and sources of information used to make decisions about COVID-19 vaccine.

RESULTS

Vaccination for COVID-19 was considered important by 75 % of 2223 students surveyed; 68 % agreed with mandating COVID-19 vaccine. Over 89 % were fully COVID-19 vaccinated (≥2 doses), 65 % were up-to-date (≥3 doses), but only 35 % had received the BA.4/BA.5 booster. Students who considered COVID-19 vaccine important were generally older, female, and non-business majors. Higher rates of up-to-date COVID-19 vaccination were found in those who received influenza vaccine in 2022-2023, females, Asians, doctoral or professional students, those attending larger universities, non-US residents, and those interested in learning more about COVID-19 vaccines. Most trusted sources of information on COVID-19 vaccines were the Centers for Disease Control and Prevention, healthcare providers, and parents; the least trusted sources were social media, television, and the internet.

CONCLUSIONS

The majority of university students agreed that COVID-19 vaccination is important and supported COVID-19 mandates. While the rate of fully vaccinated and up-to-date students was similar to the US adult population, the latter rate needs improvement. Receipt of the BA.4/BA.5 booster was particularly low. Further education is needed to improve vaccine knowledge, especially as we move to periodic boosters. Business majors, males, and younger students may benefit from increased on-campus vaccine education initiatives.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Coronavirus disease 2019 (COVID-19) vaccination rates and staffing shortages among healthcare personnel in nursing homes before, during, and after implementation of mandates for COVID-19 vaccination among 15 US jurisdictions, National Healthcare Safety Network, June 2021-January 2022

OBJECTIVE

To examine temporal changes in coverage with a complete primary series of coronavirus disease 2019 (COVID-19) vaccination and staffing shortages among healthcare personnel (HCP) working in nursing homes in the United States before, during, and after the implementation of jurisdiction-based COVID-19 vaccination mandates for HCP.

SAMPLE AND SETTING

HCP in nursing homes from 15 US jurisdictions.

DESIGN

We analyzed weekly COVID-19 vaccination data reported to the Centers for Disease Control and Prevention's National Healthcare Safety Network from June 7, 2021, through January 2, 2022. We assessed 3 periods (preintervention, intervention, and postintervention) based on the announcement of vaccination mandates for HCP in 15 jurisdictions. We used interrupted time-series models to estimate the weekly percentage change in vaccination with complete primary series and the odds of reporting a staffing shortage for each period.

RESULTS

Complete primary series vaccination among HCP increased from 66.7% at baseline to 94.3% at the end of the study period and increased at the fastest rate during the intervention period for 12 of 15 jurisdictions. The odds of reporting a staffing shortage were lowest after the intervention.

CONCLUSIONS

These findings demonstrate that COVID-19 vaccination mandates may be an effective strategy for improving HCP vaccination coverage in nursing homes without exacerbating staffing shortages. These data suggest that mandates can be considered to improve COVID-19 coverage among HCP in nursing homes to protect both HCP and vulnerable nursing home residents.

A survey of university students on attitudes, behaviors, and intentions toward influenza vaccination

Objective To determine attitudes, behaviors, and intentions of university students regarding influenza vaccination.ParticipantsUndergraduate, graduate, and professional students enrolled at a private, midwestern university.Methods A 24-item electronic survey was designed and distributed after literature review and inputs from experts on immunizations. Bivariate tests were performed to observe differences between various subgroups of respondents (age, gender, race/ethnicity, housing, and academic program). Multivariate logistic regression was performed to find associations with their vaccination preferences.Results Of 3,267 complete responses (36.3% of total students), 75% reported obtaining influenza vaccination in 2016-2017. Vaccination rates were highest for Asian (81.0%) and lowest for Black students (59.6%). Health professional student vaccination rates of 89.3% were achieved with a vaccination mandate in place. Lowest immunization rates were identified for law (47.1%) and business (52.7%) students. Positive promotional factors were identified.Conclusions Access to free, on-campus vaccinations, mandates and promotional efforts are associated with high influenza vaccination rates.

Influenza vaccine coverage among healthcare workers: A cluster analysis from a cross-sectional survey

OBJECTIVES

Influenza vaccination is recommended for healthcare workers (HCWs). However, in a 1500-bed tertiary care university hospital in France, influenza vaccine coverage among HCWs was 23% in 2017.

PATIENTS AND METHODS

We performed a cross-sectional study between 05/09/2018 and 25/09/2018 among HCWs, randomly selected independent of their vaccination status, to estimate influenza vaccination coverage rate during the 2017-2018 season, and explore factors influencing vaccination, using a questionnaire. Multivariable regression analysis to assess factors associated with vaccine uptake and hierarchical clustering on principal components to identify HCW profiles regarding factors influencing vaccine uptake, were performed after multiple imputation.

RESULTS

977 HCWs were included (68% participation rate), primarily females (84%), nurses (38%) of 18-39 years old. Influenza vaccination coverage rate reached 33[30-36]%. Frequent vaccination (aOR 39.27[21.52-74.51]) and personal/family medical history of influenza (aOR 3.33[1.16-10.02]) were independently associated with vaccination. In HCWs' patterns of influenza vaccination status, three clusters were identified: 1) (n = 438) mostly vaccinated (70%); 2) (n = 507) most unvaccinated (97%); and 3) (n = 32) unvaccinated HCWs lacking knowledge on influenza and influenza vaccine. Among the 148 (15%) HCWs reluctant to receive the vaccine the following year, 23 (16%) received it for the 2017-2018 season, while 125 (84%) did not, mostly stating they had doubts about the vaccine (82%).

CONCLUSION

This work identifies determinants of vaccine uptake and highlights HCWs profiles associated with factors influencing vaccination and a subgroup of HCWs flexible about having the vaccine during the upcoming seasonal campaign. This result opens up perspectives toward improved vaccination coverage among HCWs.

COVID-19 vaccine uptake before and after a vaccine mandate at a major academic hospital: Trends by race/ethnicity and level of patient contact

OBJECTIVES

To assess vaccine coverage rates before and after implementation of a COVID-19 vaccine mandate among Health care Personnel (HCP) and demographic characteristics associated with vaccine uptake Design, Setting, and Participants: Cohort study conducted among 10,889 hospital employees followed from Dec 16, 2020 - October 31, 2021, at a large academic hospital in Philadelphia.

MAIN OUTCOME AND MEASURES

Time to COVID-19 vaccination and vaccine series completion rates before and after implementation of a COVID-19 vaccine mandate based on age, gender, race/ethnicity, and level of patient contact/occupational group.

RESULTS

The vaccination series completion rate was 86.0% prior to mandate announcement, and increased to 98.7% after mandate implementation. Rates before mandate announcement were highest among Asians (96.2%), Whites (94.0%), males (89.7%), employees ≥ 65 years of age (95.2%), and employees with direct patient care (physicians, 99.0%, and nurses, 93.3%). Hospital educational initiatives (including Town Halls and discussions with Black and Hispanic employees with the lowest vaccination rates) appeared to improve uptake. The largest increase in series completion after mandate announcement occurred among Blacks, those of other/multiracial backgrounds, and Hispanics (35.6%, 22.4%, and 10.8%, respectively) as well as those with some or no direct patient contact (24.5% and 18.3%, respectively). Medical or religious exemptions were approved for 64 (<0.6%) employees and 38 (<0.4%) left their positions (8 voluntary, 30 involuntary) specifically due to the COVID-19 vaccine mandate. No clinically meaningful differences by age, gender, or race/ethnicity for those who were vaccinated under the mandate versus those who left their positions were noted.

CONCLUSIONS AND RELEVANCE

These results suggest that while mandates may be challenging to institutions and enforcement unpopular, they play an important role in reducing hesitancy and securing high vaccination rates among HCP, a group at high risk of COVID-19 given their employment and who can be a source of disease transmission to patients.

The effect of vaccine mandate announcements on vaccine uptake in Canada: An interrupted time series analysis

Introduction

In 2021, the ten provinces in Canada enacted COVID-19 vaccine mandates that restricted access to non-essential businesses and services to those that could provide proof of full vaccination to decrease the risk of transmission and provide an incentive for vaccination. This analysis aims to examine the effects of vaccine mandate announcements on vaccine uptake over time by age group and province.

Methods

Aggregated data from the Canadian COVID-19 Vaccination Coverage Surveillance System (CCVCSS) were used to measure vaccine uptake (defined as the weekly proportion of individuals who received at least one dose) among those 12 years and older following the announcement of vaccination requirements. We performed an interrupted time series analysis using a quasi-binomial autoregressive model adjusted for the weekly number of new COVID-19 cases, hospitalizations, and deaths to model the effect of mandate announcements on vaccine uptake. Additionally, counterfactuals were produced for each province and age group to estimate vaccine uptake without mandate implementation.

Results

The times series models demonstrated significant increases in vaccine uptake following mandate announcement in BC, AB, SK, MB, NS, and NL. No trends in the effect of mandate announcements were observed by age group. In AB and SK, counterfactual analysis showed that announcement were followed by 8 % and 7 % (310,890 and 71,711 people, respectively) increases in vaccination coverage over the following 10 weeks. In MB, NS, and NL, there was at least a 5 % (63,936, 44,054, and 29,814 people, respectively) increase in coverage. Lastly, BC announcements were followed by a 4 % (203,300 people) increase in coverage.

Conclusion

Vaccine mandate announcements could have increased vaccine uptake. However, it is difficult to interpret this effect within the larger epidemiological context. Effectiveness of the mandates can be affected by pre-existing levels of uptake, hesitancy, timing of announcements and local COVID-19 activity.

Racial/ethnic disparities in influenza risk perception and vaccination intention among Pima County residents in Arizona

While influenza cases in Arizona have nearly tripled since 2018, vaccination rates continue to lag. Statewide, Hispanics and African Americans had the lowest vaccination rates despite having higher influenza infection rates than Whites. Given Arizona's racial influenza vaccination disparity and the general increase in vaccination hesitancy due to COVID-19, the purpose of this study was to better understand the influences of seasonal influenza vaccination in Arizona during the COVID-19 pandemic using qualitative methods. Findings from this study revealed that many participants were motivated to get the influenza vaccine to protect their family and close friends. The heightened concern for COVID-19 prompted some Hispanic/Latino focus group discussion participants to consider getting vaccinated. However, many Hispanic/Latino participants also expressed that they stopped getting influenza vaccine due to negative vaccination experiences or concern about sickness following immunization. African American participants primarily discussed receiving the vaccine as part of their routine health visit. Compared to other races, more White participants believed that vaccination was unimportant because they were healthy, and the people they interacted with never got sick. Distinct factors influence risk perception and vaccination intention across different racial/ethnic groups. Effective interventions can account for these factors and be tailored to the target population to maximize vaccination uptake.

How a generally well-accepted measles vaccine mandate may lead to inequities and decreased vaccine uptake: a preregistered survey study in Germany

Background

In Germany, a measles vaccine mandate came into effect in March 2020, requiring proof of measles immunization for children attending kindergarten or school and for staff in a variety of facilities. Mandates can be successful if implemented with care and in a context-sensitive manner. They may, however, also lead to inequities and decreased uptake of other vaccines. The aim of this study was to investigate the acceptance and potential unintended consequences of the measles vaccine mandate in Germany.

Methods

As part of a larger evaluation project on the new mandate, we conducted an online survey among parents in August/September 2020. We assessed differences in knowledge about the mandate and the measles vaccine by socio-economic status. We used linear and logistic regression to estimate how reactance to the mandate was associated with vaccination status and vaccination intention against other diseases. We used mediation analysis to measure how trust in institutions had an impact on the attitude towards the mandate, mediated by level of reactance.

Results

In total, 4,863 parents participated in the study (64.2% female, mean age = 36.8 years). Of these, 74.1% endorsed a measles vaccine mandate for children. Parents with lower socio-economic status had less knowledge about the mandate and the measles vaccine. The higher parents’ levels of reactance, the lower the vaccination intentions and the likelihood for the child to be vaccinated against other diseases. Furthermore, higher institutional trust decreased the level of reactance and increased positive attitudes towards the mandate (partial mediation).

Conclusions

The new measles vaccine mandate in Germany, though well accepted by many, might have unintended consequences. Parents with lower socio-economic status, who know less about the mandate and vaccine, might be less likely to comply with it. The mandate may also lead to some parents omitting other childhood vaccines, as a way to restore their freedom. This could decrease vaccination coverage of other vaccines. Any potential loss of trust might provoke more reactance and lower acceptance of mandates. Policymakers should now expand communication activities on the mandate, monitor trends in vaccination coverage carefully and take measures to strengthen trust.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14075-y.

The Role of Psychological Factors and Vaccine Conspiracy Beliefs in Influenza Vaccine Hesitancy and Uptake among Jordanian Healthcare Workers during the COVID-19 Pandemic

Vaccination to prevent influenza virus infection and to lessen its severity is recommended among healthcare workers (HCWs). Health professionals have a higher risk of exposure to viruses and could transmit the influenza virus to vulnerable patients who are prone to severe disease and mortality. The aim of the current study was to evaluate the levels of influenza vaccine acceptance and uptake as well as its determinants, among Jordanian HCWs over the last influenza season of 2021/2022. This study was based on a self-administered electronic survey that was distributed in March 2022. Psychological determinants of influenza vaccine acceptance and vaccine conspiracy beliefs were assessed using the previously validated 5C scale questionnaire (confidence, complacency, constraints, calculation and collective responsibility) and the vaccine conspiracy beliefs scale. The study sample comprised a total of 1218 HCWs: nurses (n = 412, 33.8%), physicians (n = 367, 30.1%), medical technicians (n = 182, 14.9%), pharmacists (n = 161, 13.2%) and dentists (n = 87, 7.1%), among others. About two-thirds of the study sample expressed willingness to receive influenza vaccination if provided free of charge (n = 807, 66.3%), whereas less than one-third were willing to pay for the vaccine (n = 388, 31.9%). The self-reported uptake of the influenza vaccine in the last influenza season was 62.8%. The following factors were significantly associated with higher acceptance of influenza vaccination if provided freely, as opposed to vaccine hesitancy/rejection: male sex; physicians and dentists among HCW categories; higher confidence and collective responsibility; and lower complacency, constraints and calculation. Higher influenza vaccine uptake was significantly correlated with nurses and physicians among HCW categories, older age, a higher monthly income, higher confidence and collective responsibility, lower complacency and constraints and lower embrace of general vaccine conspiracy beliefs. The results of the current study can provide helpful clues to improve influenza vaccine coverage among HCWs in Jordan. Consequently, this can help to protect vulnerable patient groups and reserve valuable resources in healthcare settings. Psychological determinants appeared to be the most significant factors for vaccine acceptance and uptake, whereas the embrace of general vaccine conspiracy beliefs was associated with lower rates of influenza vaccine uptake, which should be considered in educational and interventional measures aiming to promote influenza vaccination.

COVID-19 vaccination intention and activation among health care system employees: A mixed methods study

BACKGROUND

Achieving high COVID-19 vaccination rates among employees is necessary to prevent outbreaks in health care settings. The goal of the study was to produce actionable and timely evidence about factors underlying the intention and decisions to obtain the COVID-19 vaccine by employees.

METHODS

The study was conducted from December 2020 - May 2021 with employees from a VA health care system in Southeastern US. The study used a convergent mixed methods design comprising two main activities: a cross-sectional survey conducted prior to COVID-19 vaccine distribution, and semi-structured interviews conducted 4-6 months after vaccine distribution. Data were collected about participant characteristics, vaccination intention prior to distribution, vaccination decision post-distribution, determinants of vaccination intention and decision, activating factors, sources of information and intervention needs. Data from the survey and interviews were analyzed separately and integrated narratively in the discussion.

RESULTS

Prior to vaccine distribution, 77% of employees wanted to be vaccinated. Post vaccine distribution, we identified 5 distinct decision-making groups: 1) vaccine believers who actively sought vaccination and included those sometimes described as "immunization advocates", 2) go along to get along (GATGA) individuals who got vaccinated but did not actively seek it, 3) cautious acceptors who got the COVID-19 vaccine after some delay, 4) fence sitters who remained uncertain about getting vaccinated, and 5) vaccine refusers who actively rejected the COVID-19 vaccine. Participants identifying with Black or multiple races were more likely to express hesitancy in their vaccination intention.

CONCLUSION

The findings of our study highlight distinct decision-making profiles associated with COVID-19 vaccination among employees of a VA health care system, and provide tailored recommendations to reduce vaccine hesitancy in this population.

Records request response rate and vaccination status of first-time college students at a mid-sized Midwestern university

Objective: The purpose of this study was to establish the response rate of first-time college students to a vaccination records request, and to obtain student vaccination rates for selected vaccines. Participants: Student health records for the fall 2018 cohort of first-time college students were reviewed. Methods: Vaccination and response rates were compared based on sex, race/ethnicity, and home state. Results: There was a 66% response rate to the vaccination records request with no difference in response rate based on student demographics. Students exceeded most of the Healthy Campus 2020 vaccination targets. The human papillomavirus (HPV) and meningitis ACWY vaccines had the greatest room for improvement. Female students were significantly more likely to have a completed HPV vaccine series. Conclusions: Records response rates may be improved by students accessing and reporting state vaccination information during a required orientation. Following (CDC) guidelines for vaccination success may improve vaccination rates for HPV and menACWY.

'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.

Mandatory COVID-19 Vaccination for Healthcare Professionals and Its Association With General Vaccination Knowledge: A Nationwide Cross-Sectional Survey in Cyprus

COVID-19 compulsory vaccination for healthcare professionals (HCPs) is a sensitive and controversial topic, with different support rates worldwide. Previous studies in Cyprus identified a low COVID-19 vaccination acceptance among HCPs, however, no studies have investigated their perceptions toward mandatory COVID-19 vaccination. This is the first study to investigate the attitudes of HCPs toward mandatory COVID-19 vaccination and its association with general vaccination knowledge. A cross-sectional study was conducted, using an online self-administered, anonymous questionnaire to collect data on sociodemographic and health-related characteristics, trust and satisfaction with the healthcare system, utilization of preventive healthcare services, COVID-19 vaccination information, vaccination knowledge, and attitudes among HCPs toward mandatory COVID-19 vaccination. A total of 504 HCPs participated in the survey, with 34% being in favor of mandatory COVID-19 vaccination. A sufficient vaccination knowledge score was identified among the HCPs, with higher scores being associated with mandatory vaccination support (p < 0.001). As age increases by one year, the odds of supporting mandatory vaccination increase by 1.03 units (95% CI: 1.01-1.06). In addition, as the general vaccination knowledge score increases by one unit, the odds of supporting mandatory COVID-19 vaccination increase by 1.55 units (95% CI: 1.33-1.81). Our findings show that about two-thirds of the HCPs in Cyprus were opposed to a mandatory COVID-19 vaccination policy. Older age and general vaccination knowledge were found to be the strongest predictors of mandatory vaccination support. To avoid unforeseen outcomes, mandatory vaccination policies should be implemented with caution and consultation.

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.

Support among healthcare workers for the new mandatory seasonal influenza vaccination policy and its effects on vaccination coverage

INTRODUCTION

Finland was the first European country to introduce a nation-wide mandatory seasonal influenza vaccination policy for healthcare workers (HCWs) by mandating that administrators of health care institutions only employ vaccinated HCWs. In this study, we examine the effects of the new policy and the view of HCWs on the new policy.

METHODS

A cross-sectional observational study was conducted in Kuopio University Hospital among HCWs working in close patient contact. The statistics on vaccination coverage were obtained from the hospital's own databases, where employees were asked to self-report their suitability for work. An anonymous survey was sent to HCWs in 2015-2016 (n = 987) and 2018-2019 (n = 821).

RESULTS

Vaccination coverage increased from 59.5 to 99.6%, according to the hospital's own records. Among the survey respondents, the seasonal influenza vaccination coverage of HCWs increased from 68.2 to 95.4%. 83.8% of doctors and 49.4% of nurses supported the new policy. 12.7% of doctors and 41.5% of nurses found the new mandate coercive or that it restricted their self-determination.

CONCLUSIONS

Our study confirms the positive effects of mandating the administrators of health care institutions to only employ vaccinated HCWs. The majority (57.9%) of all HCWs supported the new policy, with doctors being more compliant than nurses. Key messages Finland became the first European country to mandate influenza vaccination for HCWs by mandating that administrators of health care institutions only employ vaccinated HCWs. After the new act, the vaccination coverage of HCWs increased close to 100%. Most of the HCWs supported the new act and did not find it coercive.

Influenza vaccination coverage among emergency department personnel is associated with perception of vaccination and side effects, vaccination availability on site and the COVID-19 pandemic

Introduction

Influenza is a major concern in hospitals, including the emergency department (ED), mainly because of a high risk for ED personnel to acquire and transmit the disease. Although influenza vaccination is recommended for health care workers, vaccination coverage is low.

Methods

This survey was conducted in the 2016/2017 and 2020/2021 influenza seasons. Questionnaires were sent to ED personnel in 12 hospitals in Bavaria, South-Eastern Germany. The response rates were 62% and 38% in 2016/2017 and 2020/2021, respectively. Data were compared between the two seasons as well as between vaccinated and not vaccinated respondents in 2020/2021.

Results

Significantly more ED personnel reported having been vaccinated in the 2020/2021 season. Factors associated with vaccination coverage (or the intention to get vaccinated) were profession (physician / medical student), having been vaccinated at least twice, the availability of an influenza vaccination on site (in the ED) as well as the COVID-19 pandemic. Additionally, significant differences in the assessment and evaluation of influenza, its vaccination side effects and ethical aspects were found between vaccinated and not vaccinated ED personnel in 2020/2021. Unvaccinated respondents estimated higher frequencies of almost all potential vaccination side effects, were less likely to accept lay-offs if employees would not come to work during an influenza pandemic and more likely to agree that work attendance should be an employee´s decision. Vaccinated participants instead, rather agreed that vaccination should be mandatory and were less likely to consider job changes in case of a mandatory vaccination policy.

Conclusion

The COVID-19 pandemic might have contributed to a higher influenza vaccination rate among ED workers. Vaccination on site and interventions targeting the perception of influenza vaccination and its side effects may be most promising to increase the vaccination coverage among ED personnel.

Implementation of a Mandatory Influenza Vaccine Policy: A 10-Year Experience

BACKGROUND

Influenza vaccination of healthcare workers (HCWs) has been recommended for more than 30 years. In 2009, HCWs were designated as a priority group by the Centers for Disease Control and Prevention. Current HCW vaccination rates are 78% across all settings and reach approximately 92% among those employed in hospital settings. Over the last decade, it has become clear that mandatory vaccine policies result in maximal rates of HCW immunization.

METHODS

In this observational 10-year study, we describe the implementation of a mandatory influenza vaccination policy in a dedicated quaternary pediatric hospital setting by a multidisciplinary team. We analyzed 10 years of available data from deidentified occupational health records from 2009-2010 through the 2018-2019 influenza seasons. Descriptive statistics were performed using Stata v15 and Excel.

RESULTS

Sustained increases in HCW immunization rates above 99% were observed in the 10 years postimplementation, in addition to a reduction in exemption requests and healthcare-associated influenza. In the year of implementation, 145 (1.6%) HCWs were placed on temporary suspension for failure to receive the vaccine without documentation of an exemption, with 9 (0.06%) subsequently being terminated. Since then, between 0 and 3 HCWs are terminated yearly for failure to receive the vaccine.

CONCLUSIONS

Implementation of our mandatory influenza vaccination program succeeded in successfully increasing the proportion of immunized HCWs at a quaternary care children's hospital, reducing annual exemption requests with a small number of terminations secondary to vaccine refusal. Temporal trends suggest a positive impact on the safety of our patients.

Understanding implementation science from the standpoint of health organisation and management: an interdisciplinary exploration of selected theories, models and frameworks

Purpose

As a discipline, health organisation and management is focused on health-specific, collective behaviours and activities, whose empirical and theoretical scholarship remains under-utilised in the field of implementation science. This under-engagement between fields potentially constrains the understanding of mechanisms influencing the implementation of evidence-based innovations in health care. The aim of this viewpoint article is to examine how a selection of theories, models and frameworks (theoretical approaches) have been applied to better understand phenomena at the micro, meso and macro systems levels for the implementation of health care innovations. The purpose of which is to illustrate the potential applicability and complementarity of embedding health organisation and management scholarship within the study of implementation science.

Design/methodology/approach

The authors begin by introducing the two fields, before exploring how exemplary theories, models and frameworks have been applied to study the implementation of innovations in the health organisation and management literature. In this viewpoint article, the authors briefly reviewed a targeted collection of articles published in the Journal of Health Organization and Management (as a proxy for the broader literature) and identified the theories, models and frameworks they applied in implementation studies. The authors then present a more detailed exploration of three interdisciplinary theories and how they were applied across three different levels of health systems: normalization process theory (NPT) at the micro individual and interpersonal level; institutional logics at the meso organisational level; and complexity theory at the macro policy level. These examples are used to illustrate practical considerations when implementing change in health care organisations that can and have been used across various levels of the health system beyond these presented examples.

Findings

Within the Journal of Health Organization and Management, the authors identified 31 implementation articles, utilising 34 theories, models or frameworks published in the last five years. As an example of how theories, models and frameworks can be applied at the micro individual and interpersonal levels, behavioural theories originating from psychology and sociology (e.g. NPT) were used to guide the selection of appropriate implementation strategies or explain implementation outcomes based on identified barriers and enablers to implementing innovations of interest. Projects aiming to implement change at the meso organisational level can learn from the application of theories such as institutional logics, which help elucidate how relationships at the macro and micro-level have a powerful influence on successful or unsuccessful organisational action. At the macro policy level, complexity theory represented a promising direction for implementation science by considering health care organisations as complex adaptive systems.

Originality/value

This paper illustrates the utility of a range of theories, models and frameworks for implementation science, from a health organisation and management standpoint. The authors’ viewpoint article suggests that increased crossovers could contribute to strengthening both disciplines and our understanding of how to support the implementation of evidence-based innovations in health care.

Current understandings of the impact of mandatory vaccination laws in Europe

Vaccinations are among the most successful preventive tools to protect collective health. In response to alarming vaccines preventable diseases (VPDs) outbreaks resurgence, decreased vaccination coverage and vaccine refusal, several European countries have recently revised their vaccination policies introducing or extending mandatory vaccinations. This review examines the health, political and ethical aspects of mandatory vaccination.The authors first clarify terms and definitions and propose a conceptual framework of mandatory policies. Second, they describe the current status of mandatory childhood immunization programmes in Europe, assessing selected mandatory laws. Third, as the authors conduct a systematic review of the literature (retrieving from Medline 17 relevant records between 2010 and 2020), they take an analytical approach to measure the impact of mandatory vaccination policies on both VPDs control and immunization coverage, but also on population attitudes toward vaccines. 40% of European countries currently have mandatory vaccination policies; however, policies vary widely and, although there is evidence of increased vaccine uptake, their impact on informed adherence to preventive behaviors is scant.Although mandatory vaccination policies might be needed to protect collective health in times of emergency, public health goals of VPD prevention and health promotion should primarily be pursued through health education and population empowerment.

Changing attitudes towards annual influenza vaccination amongst staff in a Tertiary Care Irish University Hospital

Background

Healthcare workers are encouraged annually to get vaccinated against influenza. This year in view of COVID-19 pandemic, attitudes of HCWs towards vaccination are particularly important. A cross-sectional study was completed to understand how to best encourage and facilitate the vaccination of HCWs based on the previous years’ findings.

Methods

An online survey was disseminated to all hospital staff via electronic channels. The clinical audit sphinx software was used for data collection and analysis.

Results

The total number of responses was n = 728, almost double the rate from 2018 (N = 393). A total of 78% (N = 551) of participants were vaccinated last year. A total of 94% (N = 677) of participants reported their intention to be vaccinated this year. The main barriers listed were being unable to find time (32%, N = 36), side effects (30%, N = 33) and thinking that it does not work (21%, N = 23). The most popular suggestions for how to increase uptake were more mobile immunisation clinics (72%, N = 517) and more information on the vaccine (50%, N = 360). A total of 82% of participants (N = 590) agreed that healthcare workers should be vaccinated, with 56% (N = 405) agreeing that it should be mandatory. Of the participants who were not vaccinated last year (N = 159), 40% (N = 63) agreed that COVID-19 had changed their opinion on influenza immunisation with a further 11% (N = 18) strongly agreeing.

Discussion

In light of the increasing number of survey participants, more staff were interested in flu vaccination this year than ever before. The COVID-19 pandemic has had some influence on staff’s likelihood to be vaccinated. Feasibility of immunisation and education posed the largest barriers to HCW vaccination.

Spoonful of honey or a gallon of vinegar? A conditional COVID-19 vaccination policy for front-line healthcare workers

Seven COVID-19 vaccines are now being distributed and administered around the world (figure correct at the time of submission), with more on the horizon. It is widely accepted that healthcare workers should have high priority. However, questions have been raised about what we ought to do if members of priority groups refuse vaccination. Using the case of influenza vaccination as a comparison, we know that coercive approaches to vaccination uptake effectively increase vaccination rates among healthcare workers and reduce patient morbidity if properly implemented. Using the principle of least restrictive alternative, we have developed an intervention ladder for COVID-19 vaccination policies among healthcare workers. We argue that healthcare workers refusing vaccination without a medical reason should be temporarily redeployed and, if their refusal persists after the redeployment period, eventually suspended, in order to reduce the risk to their colleagues and patients. This 'conditional' policy is a compromise between entirely voluntary or entirely mandatory policies for healthcare workers, and is consistent with healthcare workers' established professional, legal and ethical obligations to their patients and to society at large.

Joining the herd? U.S. public opinion and vaccination requirements across educational settings during the COVID-19 pandemic

With effective and safe COVID-19 vaccines beginning to be distributed across the United States, questions about who should receive the vaccine first have been the focus of public discussions. Yet, over the long-term, questions about the order of distribution will be displaced by questions about how to achieve high levels of vaccination rates. Historically, absent incentives or mandates, Americans have shown ambivalence, if not general antipathy, towards vaccinations, and vaccination rates have generally been low for many vaccines. There is evidence that vaccination requirements across educational settings are an effective policy instrument to increase vaccination rates. We administered a large national survey to assess American's attitudes towards vaccination requirements across three educational settings (daycare, K-12 schools, and universities) in general and for COVID-19 specifically. Partisanship, gender, race, rurality, and perceptions about the appropriate role schools should play in providing health services are substantive predictors of public opinion. While Americans generally support vaccination mandates across all three settings for both types of requirements, support is consistently and significantly lower for COVID19 requirements. The effect of partisanship is accentuated for COVID-19 requirements as compared to general requirements. Drop off in support between general and COVID-19 specific requirements are driven by partisanship, gender, political knowledge, rurality, and having children in the household. Nonetheless, mandates are supported by a majority of Americans. Assessing Americans' opinions of vaccination requirements in educational settings offers an important opportunity to explore the potential of mandates as policy instrument in the government's arsenal against COVID-19 and guide public policy on the issues.

Healthcare staff perceptions towards influenza and potential COVID-19 vaccination in the 2020 pandemic context

The COVID-19 pandemic generated renewed focus on infectious disease transmission in healthcare settings. This study aimed to evaluate staff perceptions towards influenza vaccination in the COVID-19 context. All healthcare workers within a major UK tertiary referral hospital were invited to answer a survey conducted from September 2^nd to 13^th, 2020. In all, 593 responses were received across a spectrum of roles; 44% reported they were more likely to get an influenza vaccine this year due to COVID-19; however, 10% felt that an influenza vaccine was less important due to social distancing. Additional questions evaluated intention to receive COVID-19 vaccination. There were substantial differences of opinion between staff groups.

Barriers and facilitators to influenza-like illness absenteeism among healthcare workers in a tertiary-care healthcare system, 2017-2018 influenza season

OBJECTIVE

Influenza can be introduced and propagated in healthcare settings by healthcare workers (HCWs) working while ill with influenza. However, reasons driving this behavior are unclear. In this study, we examined barriers to and facilitators of absenteeism during the influenza season.

DESIGN

Cross-sectional mixed methods study.

SETTING

Ambulatory and inpatient settings in a large, tertiary-care healthcare system.

METHODS

An anonymous electronic survey was sent to HCWs between June 11 and July 13, 2018, asking participants to self-report influenza-like illness (ie, ILI symptoms of fever, chills, cough, or sore throat) during the 2017-2018 influenza season. We conducted a logistical regression analysis to identify factors associated with absenteeism.

RESULTS

Of 14,250 HCWs, 17% responded to the survey. Although 1,180 respondents (51%) reported symptoms of ILI, 575 (43%) did not stay home while ill. The most commonly perceived barriers to ILI absenteeism included being understaffed (odds ratio [OR], 1.78; P = .04), unable to find a replacement for work (OR, 2.26; P = .03), desiring not to use time off (OR, 2.25; P = .003), and paid by the hour or unable to afford being absent (OR, 2.05; P = .02). Common perceived facilitators of absenteeism included support from coworkers and management, clearer policy, better sick days availability, and lower perceived threat of disciplinary action.

CONCLUSIONS

Reporting to work with ILI symptoms is common among HCWs. Most barriers and facilitators are related to systems. Addressing system factors, such as policies regarding sick days and sick leave and ensuring adequate backup staffing, is likely to facilitate absenteeism among ill HCWs.

Increasing influenza vaccination coverage in healthcare workers: a review on campaign strategies and their effect

Purpose

Increasing influenza vaccination coverage in healthcare workers is a challenge. Especially during the ongoing COVID-19 pandemic, high vaccination coverage should be attained. This review analyzed strategies to increase influenza vaccination coverage in healthcare workers.

Methods

A literature search using PubMed was conducted and 32 publications on influenza vaccination campaigns for healthcare workers were reviewed for key interventions and resulting vaccination coverage.

Results

Among key interventions analyzed, mandatory vaccination policies or multifaceted campaigns including a vaccinate-or-wear-a-mask policy as well as mandatory declination reached vaccination coverage in healthcare workers of over 90%. Although campaigns solely based on education and promotion or on-site-vaccination did not regularly exceed an absolute vaccination coverage of 40%, a substantial relative increase in vaccination coverage was reached by implementation of these strategies.

Conclusion

Mandatory vaccination policies are effective measures to achieve high overall vaccination coverage. In clinics where policies are infeasible, multifaceted campaigns comprising on-site vaccination, vaccination stands and educational and promotional campaigns as well as incentives should be implemented. Lessons learned from influenza campaigns could be implemented in future SARS-CoV-2 vaccination campaigns.

Mandatory vaccination for seasonal influenza: what are nurses' views?

BACKGROUND

Preventing seasonal influenza is a public health priority but, although the benefits of vaccinating healthcare workers (HCWs) are emphasised, seasonal influenza vaccine uptake rates remain low. Voluntary vaccination policies have been less successful in achieving high vaccine uptake when compared to mandatory policies and the persistently low vaccine uptake among HCWs has fuelled debate on whether mandatory vaccination programmes should be implemented in the interest of patient safety.

AIM

This study explored nurses' views on mandatory vaccination policy for seasonal influenza.

METHODS

A self-selected sample (n=35) of qualified nurses working in two large hospital sites in Ireland participated in five focus groups. Data were analysed using Braun and Clarke's framework.

FINDINGS

Two themes were identified: (1) mixed views on mandatory vaccination and (2) leave nurses to make their own choice on vaccination.

CONCLUSION

This study provides an understanding of nurses' views regarding mandatory vaccination policy for seasonal influenza and highlights that individual choice and autonomy are crucial for vaccine acceptance.

Use of a comprehensive program to review religious and personal seasonal influenza vaccination exemption requests by healthcare personnel

OBJECTIVE

Vanderbilt University Medical Center (VUMC) requires that all faculty and staff receive the seasonal influenza vaccine annually or receive an approved vaccine exemption, either for a medical or deeply held religious or personal belief. We sought to understand the underlying principles behind these exemption requests and their interaction with a multidisciplinary exemption review process.

DESIGN

All of the personal and religious exemption requests at VUMC for 3 consecutive influenza seasons from 2015 to 2018 were analyzed, categorizing these requests by 1 of 12 standardized employee categories and 1 of 18 unique reasons for vaccine exemption.

SETTING

Tertiary-care academic medical center.

PARTICIPANTS

Healthcare personnel (HCP).

RESULTS

Among the 3 influenza seasons, 1.1%-2.1% of all VUMC HCP requested religious or personal exemption from vaccination. The frequency of religious and personal exemption approval increased annually from 296 of 452 (65.5%) to 196 of 248 (80.2%) to 283 of 323 (87.6%) over the 3 seasons, representing a statistically significant increase each year. Of the 5 most common reasons against vaccination, 4 were explicitly religious in nature; the most common reason was that the "body is a temple or sacred." Nonclinical staff submitted the most religious and personal exemption requests of any job category, submitting approximately one-third of all requests every year.

CONCLUSIONS

These results demonstrate how detailed the personal or religious convictions behind vaccine avoidance can be among HCP and how vaccine avoidance stems from much more than simple misinformation regarding vaccination. The intersection between misinformation and personal or religious beliefs provides a unique opportunity to address HCP opinions toward vaccination in an exemption and appeals process like the one described here.

Mandatory employee vaccination as a strategy for early and comprehensive health care personnel immunization coverage: Experience from 10 influenza seasons

BACKGROUND

Influenza is responsible for thousands of deaths in the United States and presents particular challenges in health care facilities with a greater prevalence of people at increased risk for adverse outcomes. Annual influenza vaccination has long been recommended, and employer policies influence the likelihood health care personnel are immunized.

METHODS

This is a review of vaccination data maintained by a large health care organization to assess the effects of a mandatory health care personnel vaccination policy implemented during 2008-2009. Vaccination rates, timing of immunizations, and requests for medical or religious exemptions were assessed from 2006-2007 to 2017-2018.

RESULTS

The health care personnel vaccination rate was 70% during the influenza season before the mandatory policy was implemented and increased to 98.4% immediately afterward. Vaccination rates exceeded 97% during the subsequent 9 years. Religious and medical exemptions decreased at academic medical centers and remained consistent at community hospitals. Among immunized employees, the peak date for vaccination shifted to late September or early October compared to late October or early November before the mandatory policy.

CONCLUSIONS

Requiring vaccination led to sustained increases in staff vaccination coverage at academic medical centers and community hospitals. The mandatory policy also appeared to encourage earlier vaccination.

Shoulder Injury Related to Vaccine Administration: Case Series of an Emerging Occupational Health Concern

BACKGROUND

Shoulder injury related to vaccine administration (SIRVA) is an increasingly recognized complication of improper vaccine administration. Due to the growing number of mandatory workplace vaccination programs, especially for annual influenza vaccine, it is essential that occupational health providers are aware of this condition to improve prevention and/or treatment of this condition when it arises. Therefore, we describe the clinical presentation and course of treatment of five cases of SIRVA that were seen in an employer-based Occupational Health Services Clinic (OHS) after mandatory influenza vaccine administration.

METHODS

A retrospective chart review was performed for five cases of SIRVA from 2017 to 2019.

FINDINGS

Five cases met clinical definition of SIRVA as defined by the National Vaccine Injury Compensation Program. All cases were of similar characteristics including gender, age range, and body mass index (BMI). All were treated using multiple modalities including medication, physical therapy, and modified work with eventual resolution of symptoms and full return to work.

CONCLUSIONS/APPLICATION TO PRACTICE

Awareness of SIRVA is necessary in any occupational setting where vaccines are routinely administered. Avoidance of SIRVA by adhering to proper vaccination technique is crucial, as is awareness of how to recognize and manage the condition in affected employees to limit long-term impairment.

Increasing influenza immunization rates among healthcare providers in an ambulatory-based, University Healthcare Setting☆

OBJECTIVE

Despite its 'best practice' status as an intervention to combat healthcare-related influenza, many healthcare personnel (HCP) do not seek vaccinations themselves. The objective of this study was to achieve the Healthy People [HP] 2020's influenza vaccination goal of 90% among our HCP.

DESIGN

The study utilized the model for improvement, consisting of Plan-Do-Study-Act (PDSA) cycles. Each influenza season served as a PDSA cycle until the HP 2020 vaccination goal was achieved. The quality improvement (QI) study was conducted over four influenza seasons (i.e. 2014-15; 2015-16; 2016-17 and 2017-18).

SETTING

The study's setting was an ambulatory-based, university health center within a suburban university located in central New Jersey.

PARTICIPANTS

Adapting the National Vaccine Advisory Committee's definition of HCP, clinical and non-clinical staff members (n = 110) participated in the QI-study.

INTERVENTIONS

QI-interventions were centered on staff education/outreach, improved accessibility to influenza vaccines and frequent communication to staff over several PDSA cycles.

MAIN OUTCOME & RESULTS

The QI-interventions significantly increased our overall vaccination coverage on our influenza vaccination status survey from 70.2% (2011-14 influenza seasons; n = 102) to 84.9% (2014-15 influenza season; n = 93) in PDSA 1, and 91.1% (2015-16 influenza season; n = 90) in PDSA cycle 2 (χ2 = 309.53, P < 0.001). Vaccination rates remained above the 90% performance goal during our quality control/assurance measuring periods (i.e. the 2016-18 influenza seasons).

CONCLUSIONS

This study demonstrates that influenza vaccination coverage can significantly improve among HCP through the application of concurrent and multifaceted QI-interventions.

Prospective cohort study of influenza vaccine effectiveness among healthcare personnel in Lima, Peru: Estudio Vacuna de Influenza Peru, 2016-2018

Background

The Estudio Vacuna de Influenza Peru (VIP) cohort aims to describe the frequency of influenza virus infection, identify predictors of vaccine acceptance, examine the effects of repeated influenza vaccination on immunogenicity, and evaluate influenza vaccine effectiveness among HCP.

Methods

The VIP cohort prospectively followed HCP in Lima, Peru, during the 2016‐2018 influenza seasons; a fourth year is ongoing. Participants contribute blood samples before and after the influenza season and after influenza vaccination (for vaccinees). Weekly surveillance is conducted to identify acute respiratory or febrile illnesses (ARFI). When an ARFI is identified, participants self‐collect nasal swabs that are tested for influenza viruses by real‐time reverse transcriptase‐polymerase chain reaction. Influenza vaccination status and 5‐year vaccination history are ascertained. We analyzed recruitment and enrollment results for 2016‐2018 and surveillance participation for 2016‐2017.

Results

In the first 3 years of the cohort, VIP successfully contacted 92% of potential participants, enrolled 76% of eligible HCP, and retained >90% of participants across years. About half of participants are medical assistants (54%), and most provide “hands‐on” medical care (76%). Sixty‐nine percent and 52% of participants completed surveillance for >70% of weeks in years 1 and 2, respectively. Fewer weeks of completed surveillance was associated with older age (≥50 years), being a medical assistant, self‐rated health of fair or poor, and not receiving the influenza vaccine during the current season (P‐values < .05).

Conclusions

The VIP cohort provides an opportunity to address knowledge gaps about influenza virus infection, vaccination uptake, effectiveness and immunogenicity among HCP.

Attitudes of Nursing Home Staff Towards Influenza Vaccination: Opinions and Factors Influencing Hesitancy

Seasonal influenza is recognized to be a significant public health problem and a cause of death, especially in fragile persons. In nursing homes (NHs), vaccination for both residents and staff is the best preventive strategy. However, professionals' immunization rates are far from reaching the international recommended values. This study aims to describe the adherence and attitudes of NH staff towards flu vaccination and to explore staff hesitancy. A questionnaire was developed based on a literature review and on the 3Cs (confidence, complacency, convenience) of the WHO framework and administered among the staff of four NHs of a province in the northeast of Italy. Results demonstrated a low adherence towards annual vaccination (i.e., only 3% declared getting the flu vaccination each year). Complacency, confidence and convenience all showed a significant impact on the attitude towards vaccination both in univariate and multivariable analysis, with complacency being the most strongly associated area. The area of confidence resulted in strongly challenging factors. Only 24.8% of interviewees appeared trustful towards the efficacy of receiving immunization and 34% declared safety issues. Insights from the study can support the implementation of effective interventions to improve vaccination adherence in NHs. Specifically, increasing complacency by raising awareness related to the risks of influenza appears to be an essential strategy to effectively promote vaccination uptake.

Narrowing the policy gap: lessons from years 2 and 3 of the British Columbia influenza prevention policy

Influenza can be potentially fatal to vulnerable populations, particularly those in the hospital. Canada's National Advisory Committee on Immunization recommends that health-care workers (HCW) be immunized against influenza partly to avoid infecting high-risk populations. However, influenza immunization rates among HCW remain suboptimal. In 2012, health authorities across British Columbia (B.C.) implemented a province-wide influenza prevention policy requiring HCW to either be immunized or wear a mask when in patient-care areas during the influenza season. This paper describes the second of two studies focused on what was learned from years 2 and 3 of the policy. A case study approach was used to examine this policy implementation event. Qualitative data were collected through key documents and key informant interviews with members of leadership teams responsible for policy implementation. Framework analysis and Prior's approach were used to analyze data from interviews and documents, respectively. Policy implementation varied by geographic region and gaps persist in immunization tracking and discipline for noncompliance. Debate regarding the scientific evidence used to support the policy fuels resistance from particular groups. Despite these challenges, findings suggest that the policy has been habituated, largely due to consistent policy objectives. This study emphasizes the importance of ongoing inter-professional and cross-sectoral program evaluation. While adherence may be routine for many, implementation processes must continue to respond to contextual issues to narrow the gap in policy implementation and to continue to engage stakeholders to ensure compliance.

Immunization related behaviour among healthcare workers in Europe: Results of the HProImmune survey

OBJECTIVES

Vaccine preventable diseases (VPDs) continue to pose a significant threat to healthcare workers (HCWs) while immunization among this group remains low. HCWs' behaviours as well as facilitators and barriers towards their vaccination for a number of VPDs were explored through an EU-wide survey.

METHODS

HCWs across the EU answered online survey that explored attitudes and behaviours towards vaccination for a number of VPDs. Response data were adjusted based on weights estimated by HCWs' country and working profession according to WHO statistics. The survey was delivered between October 2012 and April 2014.

RESULTS

Analysis was based on responses from 5,424 HCWs from 14 European countries. The majority (86.7%) had a positive attitude regarding immunizations. HCWs considered influenza (86.4%), viral hepatitis type B (71.9%) and tuberculosis (59.1%) as higher risk diseases for occupational exposure in the workplace. However, 43.8% reported not receiving a seasonal influenza vaccine in the last 10 years and 65.6% reported not receiving the pandemic influenza vaccine in 2009. Main enablers towards immunizations included believing in vaccine protection and easy, free of charge access to vaccines in the workplace. Barriers to up-to-date immunizations differed according to disease but included concerns about short- and long-term effects.

CONCLUSION

Although the concept of mandatory vaccination seems to be favoured by many health professionals in Europe, it remains a controversial subject both among HCWs' profession categories and also among different countries. Interventions to increase vaccination among HCWs would benefit by tailoring their approach according to disease and target group.

Seasonal influenza vaccination among primary health care workers in Southwestern Saudi Arabia

Background: Vaccination of primary healthcare workers (PHCWs) help to prevent the spread of influenza among at-risk patients.Objectives: To assesses seasonal influenza vaccination (SIV) coverage and the factors affecting SIV's utilization among PHCWs in Abha city, southwestern Saudi Arabia.Methods: A cross-sectional survey was carried out between June 2018 and August 2018 in all primary healthcare centers in Abha city. It targeted physicians, nurses, technicians, and pharmacists. A self-administered questionnaire was used to collect data regarding SIV status during the 2017-2018 season, obtain knowledge regarding SIV and influenza disease, and identify potential motivators for and barriers to SIV.Results: Of 312 PHCWs, the SIV coverage rate was 45.5% in the 2017-2018 vaccination season. A multivariable logistic regression model showed that the risk groups for non-vaccination were PHCWs less than 40 years old (adjusted Odds Ratio (aOR) = 4.07, 95% CI: 1.50-11.03), technicians (aOR = 3.73, 95% CI: 1.20-11.54), single PHCWs (aOR = 2.36, 95% CI:1.20-4.62), and PHCWs lacking adequate influenza vaccine knowledge (aOR = 4.22, 95% CI: 2.13-8.35). Approximately 23% and 32% of PHCWs were found to have inadequate knowledge about SIV and influenza disease, respectively. PHCWs' awareness about their risk of infection and their need for protection was found to be the most common motivator (77.5%), and a fear of side effects was found to be the most frequent barrier (40%).Conclusion: SIV coverage rate is suboptimal. Knowledge gaps and misconceptions about the influenza vaccine are the main barriers to an adequate coverage.

Maximizing influenza vaccination uptake among healthcare personnel in Israel: lessons learned from mandatory vaccination policy in the United States

Background

Maximizing vaccination uptake is crucial in generating herd immunity and preventing infection incidence (Quach et al., Am J Infect Control 11:1017–23, 2013). Vaccination of healthcare personnel (HCP) against influenza is vital to influenza infection control in healthcare settings, given the consistent exposure of HCP to high-risk patients like: those with compromised immune systems, children, and the elderly (Johnson & Talbot, Curr Opin Infect Dis 24: 363–369, 2011). Influenza vaccination uptake among HCP remains suboptimal: in 2017–18, 47.6% of HCP who worked in settings where influenza vaccination was not mandatory were vaccinated against influenza in United States (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018). Mandatory vaccination policies result in HCP influenza vaccination uptake rates substantially higher than opt-in influenza vaccination campaigns (94.8% vs. 47.6%) (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018).

Goals

The Israel Journal of Health Policy Research has published articles focused on the issues of influenza vaccination (Yamin et al., Isr J Health Policy Res 3: 13, 2014), improving influenza vaccination coverage of HCP (Weber et al., Isr J Health Policy Res 5: 1–5, 2016), influenza vaccination motivators among HCP (Nutman and Yoeli, Isr J Health Policy Res 5: 52, 2016), legal imposition of vaccination (Kamin-Friedman, Isr J Health Policy Res 6:58, 2017), and mandatory vaccination (Gostin, Cell Biosci 8: 1-4, 2018). Each article explores factors influencing disease prevention from different angles within an Israeli context. This article attempts to fuse these topics by investigating how to apply aspects of American mandatory influenza vaccination policy targeted at HCP in an Israeli context.

Methods

Critical document analysis was conducted on relevant literature and policy discussing influenza prevention interventions among HCP within the United States. Mandatory vaccination policies were highlighted. A discussion of the professional responsibility of HCP to vaccinate against influenza serves as background. Case studies of hospitals in the United States that implemented mandatory vaccination policies for their employees are analyzed. The article concludes with analysis exploring how qualities of mandatory influenza vaccination policy of HCP could take shape in Israel, giving contextual limitations, urging Israeli health policy makers to reflect on lessons learned from the American case study.

Main findings and conclusion

Mandatory HCP influenza vaccination policies in comparison to non-mandatory interventions are most effective in obtaining maximum influenza vaccination uptake among HCP (Black et al., Morb Mortal Wkly Rep 67: 1050, 2018). Many HCP cite individual objections to influenza vaccination rooted in personal doubts and ethical concerns. The ethical responsibility of HCP to their patients and work environments to prevent and lower influenza infection incidence arguably overrules such individual objections. Mandatory HCP influenza vaccination policies are an effective method of maximizing HCP influenza vaccine uptake and minimizing the spread of the influenza virus within healthcare settings. Still, cultural, social and political sensitivity must be taken into consideration when implementing both full-on mandatory HCP influenza vaccination policies and/or aspects of mandatory policies, especially within an Israeli context.

Measuring the impact of a mandatory province-wide vaccinate-or-mask policy on healthcare worker absenteeism in British Columbia, Canada

OBJECTIVES

Vaccinate-or-mask (VOM) policies aim to improve influenza vaccine coverage among healthcare workers (HCW) and reduce influenza-related illness among patients and staff. In 2012, British Columbia (BC) implemented a province-wide VOM influenza prevention policy. This study describes an evaluation of policy impacts on HCW absenteeism rates from before to after policy implementation.

METHODS

Using payroll data from regional and provincial Health Authorities (HA), we assessed all-cause sick rates (sick time as a proportion of sick time and productive time) before (2007-2011, excluding 2009-2010) and after (2012-2017) policy implementation, and during influenza season (December 1-March 31) and non-influenza season (April 1-November 30). We used a two-part negative binomial hurdle model to calculate odds ratios (OR) of taking any sick time, relative rates (RR) of sick time taken, and predicted mean sick rates, adjusting for age group, sex, job type, job classification, HA, year and vaccine effectiveness.

RESULTS

During influenza season, HCWs in the post-policy period were less likely to take any sick time (OR 0.989, 95%CI: 0.979-0.999) but had higher rates of sick time (RR 1.038, 95%CI: 1.030-1.045). However, during non-influenza season, HCWs in the post-policy period were more likely to take any sick time (OR 1.015, 95%CI: 1.008-1.022) but had lower rates of sick time (RR 0.971, 95%CI: 0.966-0.976). There was an overall increase in predicted mean sick rate from pre to post-policy in influenza season (4.392% to 4.508%) and non-influenza season (3.815% to 3.901%).

CONCLUSIONS

The observed year-round increase in sick rates from pre-to-post policy was likely influenced by other factors; however, opposite trends in how HCWs took sick time in the influenza and non-influenza seasons may reflect policy influences and need further research to explore reasons for these differences.

Association of State Laws With Influenza Vaccination of Hospital Personnel

INTRODUCTION

Healthcare personnel influenza vaccination can reduce influenza illness and patient mortality. State laws are one tool promoting healthcare personnel influenza vaccination.

METHODS

A 2016 legal assessment in 50 states and Washington DC identified (1) assessment laws: mandating hospitals assess healthcare personnel influenza vaccination status; (2) offer laws: mandating hospitals offer influenza vaccination to healthcare personnel; (3) ensure laws: mandating hospitals require healthcare personnel to demonstrate proof of influenza vaccination; and (4) surgical masking laws: mandating unvaccinated healthcare personnel to wear surgical masks during influenza season. Influenza vaccination was calculated using data reported in 2016 by short-stay acute care hospitals (n=4,370) to the National Healthcare Safety Network. Hierarchical linear modeling in 2018 examined associations between reported vaccination and assessment, offer, or ensure laws at the level of facilities nested within states, among employee and non-employee healthcare personnel and among employees only.

RESULTS

Eighteen states had one or more healthcare personnel influenza vaccination-related laws. In the absence of any state laws, facility vaccination mandates were associated with an 11-12 percentage point increase in mean vaccination coverage (p<0.0001). Facility-level mandates were estimated to increase mean influenza vaccination coverage among all healthcare personnel by 4.2 percentage points in states with assessment laws, 6.6 percentage points in states with offer laws, and 3.1 percentage points in states with ensure laws. Results were similar in analyses restricted only to employees although percentage point increases were slightly larger.

CONCLUSIONS

State laws moderate the effect of facility-level vaccination mandates and may help increase healthcare personnel influenza vaccination coverage in facilities with or without vaccination requirements.

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.