Increasing Influenza Vaccination Among Healthcare Workers
Increasing Influenza Vaccination Among Healthcare Workers
Few methodologically rigorous studies have been published on how to successfully and sustainably raise influenza vaccine uptake rates among HCW; however, several insights emerged from our review of the available literature. We found in our limited analysis that programmes using a larger number of intervention components achieved higher vaccine coverage. Among specific strategies reported to have high success rates, the provision of free vaccine seems to be indispensable. The most effective intervention, however, appears to be a mandatory vaccination policy for healthcare workers. The three programmes that used this strategy achieved nearly universal coverage. While most studies reviewed were implemented during a single season, we found evidence that sustained efforts lead to high and sustained vaccination uptake rates.
Provision of free vaccine was used in almost all programmes at baseline, but was formally evaluated in one study where it appeared to be the crucial component to substantially improve vaccine uptake after other strategies before showed either zero or a lesser success. This finding is consistent with results of a meta-analysis of studies that have investigated self-reported reasons for non-receipt of the vaccine where inconvenient access has been identified as one of the major obstacles, particularly for physicians.
Other useful intervention components included flexible and worksite vaccine delivery, the assignment of staff dedicated to take responsibility for the programme, and provision of educational materials. Regarding the latter, an important aspect of designing educational material is that nurses and physicians will likely need to be targeted in different ways. This is supported by several studies that found that the vaccination rate of nurses was significantly lower than that of physicians, and research indicating large differences in attitudes and knowledge concerning influenza vaccination between nurses and physicians. Educational messages will likely need to be conveyed in many different ways to increase the likelihood and frequency of encounters. A recent meta-analysis on interventions for adult immunization programmes supports the notion of the potential positive effects incentives may have. Understanding knowledge and attitudes prior to the intervention has been used to tailor intervention programmes and shape the contents of educational activities to local needs and was also assessed by several studies. Although some of these tailored studies reported a substantial increase in uptake, their success could not be linked directly to the conducted survey. Because local conditions, peer opinion, cultural, institutional and logistical factors will all lead to differences in knowledge and behaviour and because reasons for refusal of the vaccine cover a wide and diverse spectrum, the use of a pre-intervention survey makes intuitive sense.
Making vaccination a mandatory condition of initial and continued HCW employment is likely to be the most controversial, but also successful method for increasing uptake. A recent survey among US HCW who reported working at a facility where vaccination was required by their employer, 98·1% were vaccinated. Insufficient vaccine uptake levels have prompted numerous healthcare facilities in the USA to institute mandatory programmes for their HCW to protect patients. Moreover, several US professional societies recommended that influenza vaccination of HCW be made mandatory, and several studies showed support for this policy among HCW in the USA and medical students in Germany. However, the vaccination mandate in the USA has met considerable resistance. HCW protested against the implementation of a vaccination requirement and made a successful legal challenge on the basis that the hospital had violated the terms of their contracts. Opponents claim that a mandate violates HCW personal autonomy and right to make medical decisions concerning their body themselves and that it may 'alienate staff and damage morale', undermine trust and negatively affect employee–employer relationship. Commentators who support mandatory vaccination assume the failure of voluntary vaccination strategies and argue that the benefits for patients outweigh burdens and risks of vaccination on behalf of the HCW and that the restrictions of HCW autonomy and freedom of choice are therefore ethically justified, unless a valid medical contraindication exists. From their perspective, mandatory programmes meet the professional values and codes of ethics adopted by HCW, that is, to do no harm and to act in patients' best interests. However, while the prevention of harm to others is a potential reason for the limitation of autonomy, mandatory measures are only justified under certain conditions. Successful programmes presented in this review have made substantial organizational and educational efforts prior to the start of the mandatory policy suggesting that a mandatory programme must not be used as the easy, administrative magic bullet, but needs at least contemporaneous or even better antecedent implementation of a multifaceted programme using other elements described in this review to maximize chances for a 'friendly reception' of the policy by staff.
One alternative or compromise may be represented by a recently published study that implemented a 'multifaceted patient safety programme' combining the institutional responsibility to protect patients from nosocomial infections with the HCWs' right for vaccine declination for any reason. The programme, which was associated with a vaccination rate of 96%, required all employees with direct patient contact to choose between vaccination and an 'appropriate non-vaccine alternative', that is, either to wear a surgical mask or to exclude patient contact. Other authors have also made the case for a 'combined approach' using 'opt-out' declination statements in conjunction with the exclusion of unvaccinated HCW from work in defined areas where the most vulnerable patients are cared for, such as ICUs, oncology, transplantation.
There is evidence, however, that sustained efforts of voluntary vaccination programmes are capable of leading to high vaccination rates nevertheless. Two institutions in the USA who observed results of their interventions for 12 and 18 years, respectively, were both able to increase vaccination uptake rates from moderately or very low levels to two-thirds of their targeted health personnel. Moreover, experience from the USA indicates that on a country-wide scale, it requires many years to raise influenza vaccination rates substantially. In 1989, the national vaccination coverage among HCW was still at the 10% level, but was estimated at 34% in 1997, 44% in 2003 and at 63·5% in 2011. These long-standing efforts would indicate a degree of management support for the programme, a likely factor in success not explicitly measured in any of the studies reviewed.
Finally, one unique intervention approach not included in our review was tried by the MOH of Germany that conducted a nationwide, low-cost, 2-year vaccination programme targeted to all hospitals in the country. The material included posters, pamphlets and briefing notes for mass mailings and a presentation for informational sessions. An evaluation of a convenience sample of 20 hospitals showed that the uptake rate increased only in those who used the material, albeit by <10% points indicating that such an approach can effectively complement and support efforts in individual hospitals to raise influenza vaccination uptake rates.
The typical study evaluated one intervention programme with multiple intervention components in one facility during a single season and the studies reported a wide variety of interventions. Consequently, our retrospective analysis has a number of limitations. First, the reporting of intervention studies is likely subject to publication bias as studies without an increase in vaccination rate after an intervention are less likely to be published. Second, although we attempted to make interventions more comparable by grouping them into distinct components, it is clear that neither individual intervention components nor intervention programmes can be standardized and any comparisons should be made with caution. Intervention components were not mutually exclusive and often one activity entailed elements of two different components. For example, worksite delivery of vaccines was often combined with education on-site. Furthermore, some single activities had overlapping purposes, so it was difficult to assign them to one intervention component. For example, there may have been reminders that repeated educational messages. Third, each component may be implemented in a number of different ways. For example, the provision of educational material may differ in wording, in the way it is presented, its appropriateness for the target audience, where and how and in which number it is presented or delivered, and of course other often intangible factors. Lastly, comparison of the effect of components also may vary depending on the type of comparison group, if a control group was included in the design, or if settings were randomized. For example, before-and-after studies without comparable control group are logistically easier but do not control for any influence from outside the intervention programme, such as vaccine shortage or changes in awareness over time.
In conclusion, the authors believe that vaccination of HCW is a key part of a strategy to prevent influenza in groups who are most at risk of complications. The reviewed literature suggests that while no single component is capable of raising influenza vaccination rates in HCW rapidly and to a relevant degree, except perhaps mandatory vaccination, a comprehensive, well-supported, well-staffed and well-planned, multifaceted vaccination intervention programme can raise uptake rates substantially and sustainably. Indeed, it seems likely that in such a multifaceted programme, the individual components described in this review would support each other and perhaps have a synergistic effect. A successful programme would contain as many elements as possible (Text box 1); however, in resource-limited settings, hospital managers might want to focus on two components that seem to be most effective in rapidly raising vaccination rates. First, flexible access to free vaccination is key to overcome time- and access-related barriers to vaccine uptake. Second, the approach for a successful HCW vaccination programme requires culturally sensitive education on the risk of influenza and the overall benefits of vaccination, tailored to specific professional characteristics. Periodic surveys can help to identify specific motivators and barriers of HCW vaccine receipt and to tailor programmes accordingly. Programmes that attain higher vaccination rates can expect in turn to reduce the risk of nosocomial influenza infections and related healthcare costs. It is also worth noting that predictor studies have found consistently that 'history of influenza vaccination' is perhaps the most reliable factor associated with vaccine receipt in the next season. While these previously vaccinated HCW represent 'low hanging fruit' for an intervention programme, it also means that HCW who have rejected the vaccine in previous years may be particularly resistant. Programmes aiming for high rates of coverage will need to target this group of HCW. Hospital managers who consider influenza vaccination uptake rates in their employees as a quality marker for their facility should be prepared to commit the required human and financial resources to meet this goal.
Discussion
Few methodologically rigorous studies have been published on how to successfully and sustainably raise influenza vaccine uptake rates among HCW; however, several insights emerged from our review of the available literature. We found in our limited analysis that programmes using a larger number of intervention components achieved higher vaccine coverage. Among specific strategies reported to have high success rates, the provision of free vaccine seems to be indispensable. The most effective intervention, however, appears to be a mandatory vaccination policy for healthcare workers. The three programmes that used this strategy achieved nearly universal coverage. While most studies reviewed were implemented during a single season, we found evidence that sustained efforts lead to high and sustained vaccination uptake rates.
Provision of free vaccine was used in almost all programmes at baseline, but was formally evaluated in one study where it appeared to be the crucial component to substantially improve vaccine uptake after other strategies before showed either zero or a lesser success. This finding is consistent with results of a meta-analysis of studies that have investigated self-reported reasons for non-receipt of the vaccine where inconvenient access has been identified as one of the major obstacles, particularly for physicians.
Other useful intervention components included flexible and worksite vaccine delivery, the assignment of staff dedicated to take responsibility for the programme, and provision of educational materials. Regarding the latter, an important aspect of designing educational material is that nurses and physicians will likely need to be targeted in different ways. This is supported by several studies that found that the vaccination rate of nurses was significantly lower than that of physicians, and research indicating large differences in attitudes and knowledge concerning influenza vaccination between nurses and physicians. Educational messages will likely need to be conveyed in many different ways to increase the likelihood and frequency of encounters. A recent meta-analysis on interventions for adult immunization programmes supports the notion of the potential positive effects incentives may have. Understanding knowledge and attitudes prior to the intervention has been used to tailor intervention programmes and shape the contents of educational activities to local needs and was also assessed by several studies. Although some of these tailored studies reported a substantial increase in uptake, their success could not be linked directly to the conducted survey. Because local conditions, peer opinion, cultural, institutional and logistical factors will all lead to differences in knowledge and behaviour and because reasons for refusal of the vaccine cover a wide and diverse spectrum, the use of a pre-intervention survey makes intuitive sense.
Making vaccination a mandatory condition of initial and continued HCW employment is likely to be the most controversial, but also successful method for increasing uptake. A recent survey among US HCW who reported working at a facility where vaccination was required by their employer, 98·1% were vaccinated. Insufficient vaccine uptake levels have prompted numerous healthcare facilities in the USA to institute mandatory programmes for their HCW to protect patients. Moreover, several US professional societies recommended that influenza vaccination of HCW be made mandatory, and several studies showed support for this policy among HCW in the USA and medical students in Germany. However, the vaccination mandate in the USA has met considerable resistance. HCW protested against the implementation of a vaccination requirement and made a successful legal challenge on the basis that the hospital had violated the terms of their contracts. Opponents claim that a mandate violates HCW personal autonomy and right to make medical decisions concerning their body themselves and that it may 'alienate staff and damage morale', undermine trust and negatively affect employee–employer relationship. Commentators who support mandatory vaccination assume the failure of voluntary vaccination strategies and argue that the benefits for patients outweigh burdens and risks of vaccination on behalf of the HCW and that the restrictions of HCW autonomy and freedom of choice are therefore ethically justified, unless a valid medical contraindication exists. From their perspective, mandatory programmes meet the professional values and codes of ethics adopted by HCW, that is, to do no harm and to act in patients' best interests. However, while the prevention of harm to others is a potential reason for the limitation of autonomy, mandatory measures are only justified under certain conditions. Successful programmes presented in this review have made substantial organizational and educational efforts prior to the start of the mandatory policy suggesting that a mandatory programme must not be used as the easy, administrative magic bullet, but needs at least contemporaneous or even better antecedent implementation of a multifaceted programme using other elements described in this review to maximize chances for a 'friendly reception' of the policy by staff.
One alternative or compromise may be represented by a recently published study that implemented a 'multifaceted patient safety programme' combining the institutional responsibility to protect patients from nosocomial infections with the HCWs' right for vaccine declination for any reason. The programme, which was associated with a vaccination rate of 96%, required all employees with direct patient contact to choose between vaccination and an 'appropriate non-vaccine alternative', that is, either to wear a surgical mask or to exclude patient contact. Other authors have also made the case for a 'combined approach' using 'opt-out' declination statements in conjunction with the exclusion of unvaccinated HCW from work in defined areas where the most vulnerable patients are cared for, such as ICUs, oncology, transplantation.
There is evidence, however, that sustained efforts of voluntary vaccination programmes are capable of leading to high vaccination rates nevertheless. Two institutions in the USA who observed results of their interventions for 12 and 18 years, respectively, were both able to increase vaccination uptake rates from moderately or very low levels to two-thirds of their targeted health personnel. Moreover, experience from the USA indicates that on a country-wide scale, it requires many years to raise influenza vaccination rates substantially. In 1989, the national vaccination coverage among HCW was still at the 10% level, but was estimated at 34% in 1997, 44% in 2003 and at 63·5% in 2011. These long-standing efforts would indicate a degree of management support for the programme, a likely factor in success not explicitly measured in any of the studies reviewed.
Finally, one unique intervention approach not included in our review was tried by the MOH of Germany that conducted a nationwide, low-cost, 2-year vaccination programme targeted to all hospitals in the country. The material included posters, pamphlets and briefing notes for mass mailings and a presentation for informational sessions. An evaluation of a convenience sample of 20 hospitals showed that the uptake rate increased only in those who used the material, albeit by <10% points indicating that such an approach can effectively complement and support efforts in individual hospitals to raise influenza vaccination uptake rates.
The typical study evaluated one intervention programme with multiple intervention components in one facility during a single season and the studies reported a wide variety of interventions. Consequently, our retrospective analysis has a number of limitations. First, the reporting of intervention studies is likely subject to publication bias as studies without an increase in vaccination rate after an intervention are less likely to be published. Second, although we attempted to make interventions more comparable by grouping them into distinct components, it is clear that neither individual intervention components nor intervention programmes can be standardized and any comparisons should be made with caution. Intervention components were not mutually exclusive and often one activity entailed elements of two different components. For example, worksite delivery of vaccines was often combined with education on-site. Furthermore, some single activities had overlapping purposes, so it was difficult to assign them to one intervention component. For example, there may have been reminders that repeated educational messages. Third, each component may be implemented in a number of different ways. For example, the provision of educational material may differ in wording, in the way it is presented, its appropriateness for the target audience, where and how and in which number it is presented or delivered, and of course other often intangible factors. Lastly, comparison of the effect of components also may vary depending on the type of comparison group, if a control group was included in the design, or if settings were randomized. For example, before-and-after studies without comparable control group are logistically easier but do not control for any influence from outside the intervention programme, such as vaccine shortage or changes in awareness over time.
In conclusion, the authors believe that vaccination of HCW is a key part of a strategy to prevent influenza in groups who are most at risk of complications. The reviewed literature suggests that while no single component is capable of raising influenza vaccination rates in HCW rapidly and to a relevant degree, except perhaps mandatory vaccination, a comprehensive, well-supported, well-staffed and well-planned, multifaceted vaccination intervention programme can raise uptake rates substantially and sustainably. Indeed, it seems likely that in such a multifaceted programme, the individual components described in this review would support each other and perhaps have a synergistic effect. A successful programme would contain as many elements as possible (Text box 1); however, in resource-limited settings, hospital managers might want to focus on two components that seem to be most effective in rapidly raising vaccination rates. First, flexible access to free vaccination is key to overcome time- and access-related barriers to vaccine uptake. Second, the approach for a successful HCW vaccination programme requires culturally sensitive education on the risk of influenza and the overall benefits of vaccination, tailored to specific professional characteristics. Periodic surveys can help to identify specific motivators and barriers of HCW vaccine receipt and to tailor programmes accordingly. Programmes that attain higher vaccination rates can expect in turn to reduce the risk of nosocomial influenza infections and related healthcare costs. It is also worth noting that predictor studies have found consistently that 'history of influenza vaccination' is perhaps the most reliable factor associated with vaccine receipt in the next season. While these previously vaccinated HCW represent 'low hanging fruit' for an intervention programme, it also means that HCW who have rejected the vaccine in previous years may be particularly resistant. Programmes aiming for high rates of coverage will need to target this group of HCW. Hospital managers who consider influenza vaccination uptake rates in their employees as a quality marker for their facility should be prepared to commit the required human and financial resources to meet this goal.