Abstract
Background:
Annual influenza vaccination is recommended for healthcare personnel (HCP). We describe influenza vaccination coverage among HCP during the 2010–2011 season, and present reported facilitators of and barriers to vaccination.
Methods:
We enrolled HCP 18–65 years of age, working full time, with direct patient contact. Participants completed an internet-based survey at enrollment and the end of influenza season. In addition to self-reported data, we collected information about the 2010–2011 influenza vaccine from electronic employee health and medical records.
Results:
Vaccination coverage was 77% (1,307/1,701). Factors associated with higher vaccination coverage include older age, being married or partnered, working as a physician or dentist, prior history of influenza vaccination, more years in patient care, and higher job satisfaction. Personal protection was reported as the most important reason for vaccination followed closely by convenience, protection of patients, and protection of family and friends. Concerns about perceived vaccine safety and effectiveness, and low perceived susceptibility to influenza were the most commonly reported barriers to vaccination. About half of the unvaccinated HCP said they would have been vaccinated if required by their employer.
Conclusions:
Influenza vaccination in this cohort was relatively high but still fell short of the recommended target of 90% coverage for HCP. Addressing concerns about vaccine safety and effectiveness are possible areas for future education or intervention to improve coverage among HCP.
Keywords: influenza, vaccination, healthcare personnel
INTRODUCTION
Influenza vaccination can protect both healthcare personnel (HCP) and their patients from influenza-related morbidity and mortality.[1] Since the early 1980s, the Advisory Committee on Immunization Practices (ACIP) has recommended annual influenza vaccination for HCP.[2] Despite this long-standing recommendation, influenza vaccination coverage rates among HCP in the United States have traditionally been low, between 30% and 50%.[1,3–5] Frequently reported barriers to vaccination among HCP include concerns about adverse reactions, low perceived vaccine efficacy, low perceived susceptibility to influenza infection, and inconvenience.[1,6] Recent literature suggests that vaccine coverage rates among HCP can be increased beyond the Healthy People 2020 goal of 90% by requiring vaccination as a condition of employment, and many institutions have recently moved forward with mandatory employee influenza vaccination programs. [7–12] However, employer required vaccination can be viewed as coercive by HCP,[13,14] and these types of policies have been the subject of much debate among healthcare administrators and professional organizations.[15–17]
This paper describes influenza vaccination coverage in a cohort of HCP using data from two healthcare delivery systems during the 2010–2011 influenza season using a combination of electronic health record and self-reported vaccination data. We also describe reported adverse events following vaccination, and present reported facilitators of and barriers to vaccination. In both delivery systems, employee vaccination was encouraged, but not required during the study period. We also describe reported attitudes towards required vaccination and use of vaccination declination forms among unvaccinated participants.
METHODS
A detailed explanation of our methods for cohort recruitment is presented in a previous publication[18] Briefly, we enrolled a prospective cohort of HCP from September through December 2010 at Scott and White Healthcare (SWH) in Temple, Texas, and at Kaiser Permanente Northwest (KPNW) in Portland, Oregon. Eligible enrollees were 18 through 65 years of age, working full-time (>32 hours per week), employed by and receiving medical care from SWH or KPNW for at least 12 months, and providing direct patient care, defined as “regular, close, face-to-face, or hands-on contact with patients as part of a typical work shift, including regular contact within 3 feet of patients for 5 minutes or more”.[19] We selected this definition of direct patient care to focus on HCP at greatest risk of influenza exposure and transmission to patients. We sent announcements and email invitations regarding a study of “respiratory illness and healthcare workers” to all employees. Participants were offered small incentives in the form of cash ($50 at SWH) or gift cards ($25 at KPNW). Study procedures were approved by Institutional Review Boards at both sites and the CDC.
Data collection
Consented participants completed an internet-based questionnaire at home or on facility computers at enrollment (Fall 2010) and post-influenza season (May/June 2011). At enrollment, participants reported their race/ethnicity, marital status, education, occupation, years of employment in patient care, and work setting (outpatient, intensive care unit, hospital, emergency department, long-term care). We collected information about participant’s history of chronic illness, household composition, and job satisfaction in the post-season survey. Participants were classified as high-risk if they reported a history of diagnosed asthma, cancer, chronic lung disease, diabetes, heart problem, immunosuppression, kidney disease, or neurologic or neuromuscular disease. We identified high-risk households as those including pregnant women, infants less than 1 year of age, adults older than 65 years of age, or persons with asthma or other chronic health conditions. Participants were asked to report their job satisfaction on a 7-point scale ranging from extremely dissatisfied (1) to extremely satisfied (7). [20]
We collected self-reported vaccination status during the enrollment survey (for the 2009–2010 pandemic H1N1 and seasonal vaccines) and at the post-season survey (for the 2010–2011 seasonal vaccine). We also collected information about receipt of the 2010–2011 influenza vaccine and up to five years of influenza vaccination history from electronic medical records and employee health records at the two sites.
Participants who reported during the post-season survey that they had received an influenza vaccine were asked a series of questions about possible vaccine adverse events (e.g., fever, hives, allergic reactions, injection site pain). They were also asked to rate the relevance of 12 factors in their decision to be vaccinated. These items were presented in random order and rated on a Likert-type scale from strongly disagree (1) to strongly agree (5). Results are presented using the following categories: vaccine benefits (protect self, protect family and friends, protect patients, avoid missing work), convenience and access (easy to get vaccine, vaccine offered free of charge, employer pays for vaccination time), and peer/employer recommendations (employer recommendation, most work colleagues get vaccinated, doctor or nurse recommendation, work colleague recommendation, employer requirement).
Participants who reported not having received an influenza vaccine at the post-season survey were asked to rate the relevance of 12 potential barriers to vaccination, again using a five-point scale (strongly disagree (1) to strongly agree (5)). We grouped these potential barriers into three broad categories: vaccine safety concerns (concerned about side effects, concerned about getting the flu from the flu shot, did not want H1N1 component of the vaccine, had a severe reaction to a prior vaccination, allergic to the vaccine), low perceived susceptibility or vaccine effectiveness (flu is not a very serious illness, flu vaccination is not needed, flu vaccines do not work, do not have contact with people who get the flu, already had the flu earlier in the season), and access to vaccine (did not know how to get a flu shot, meant to get the vaccine but did not). We asked unvaccinated participants if they made a conscious decision to be unvaccinated, or were ambivalent or “on the fence” about vaccination. We also asked two questions about vaccine requirements (“Would you have received an influenza vaccination during this flu season if it was mandatory for all health care workers, unless there was a medical reason for them not to be vaccinated?”), and the use of employee declination forms (“Would you have received an influenza vaccination during this flu season if you were required to either receive the flu vaccine or decline in writing by signing a declination form?” ). Neither of these questions specified the consequence of vaccine refusal.
Analysis
We limited our analyses to participants who completed both the enrollment and post-season surveys. We calculated 2010–2011 influenza vaccination coverage rates by dividing the number vaccinated (based on either self-report or health record) by the total number of eligible participants. We described differences in vaccination coverage by study site, demographics (age, gender, race/ethnicity, marital status), education, occupation, years in patient care, work setting, job satisfaction, high-risk conditions, household composition, and influenza-vaccination history using chi-square and t-tests. We compared the concordance between self-reported and health record vaccination status for the 2010–2011 season using Kappa statistics. We described rates of reported adverse events and reasons for vaccine acceptance among participants who reported being vaccinated, and reported barriers to vaccination among unvaccinated participants. We also described reported barriers among unvaccinated participants who reported making a decision to decline vaccination and participants who were ambivalent about vaccination. All descriptive analyses were conducted using SAS version 9.2 (SAS Institute, Cary, NC).
RESULTS
During the 2010–2011 season, the estimated influenza vaccination rate among all employees was 71% at SWH and 64% at KPNW based on employee health records. Approximately 40% of SWH and 20% of KPNW eligible HCP volunteered for the study. Of 1,834 HCP enrolled at both sites, 1,782 (97%) completed the enrollment survey. During the follow-up period, 81 participants refused subsequent participation, became ineligible due to changes in employment or insurance status, or were lost to follow-up. Ninety-three percent (n=1,701) of the initial consented cohort completed both the enrollment and post-season surveys and were included in analyses.
The 2010–2011 influenza vaccination rate (including both self-reported and health record vaccinations) for all participants was 77% (1,307/1,701). There were no significant differences noted in vaccination coverage by study site, gender, race/ethnicity, education, or work setting (Table 1). Factors associated with higher vaccine coverage included older age (50–65 years), being married or partnered, working as a physician or dentist, prior self-reported seasonal influenza and pandemic H1N1 vaccination during the 2009–2010 season, 21 or more years in patient care, and higher job satisfaction. Participants from high-risk households had a higher rate of vaccination than those from other households (82% vs. 74%, p<0.001), but the participants’ own high-risk medical status was not significantly associated with differences in vaccination coverage (80% vs. 76%, p=0.06).
Table 1.
Participant characteristics and 2010–11 influenza vaccination rates
| 2010–11 Influenza Vaccination Rate* number vaccinated/total (%) |
p-value | |
|---|---|---|
| Overall | 1307/1701 (77%) | |
| Study Site | ||
| SWH | 818/1063 (77%) | 0.89 |
| KPNW | 489/638 (77%) | |
| Gender | ||
| Male | 268/347 (77%) | 0.85 |
| Female | 1039/1354 (77%) | |
| Age | ||
| 18–34 years | 408/545 (75%) | 0.007 |
| 35–49 years | 485/650 (75%) | |
| 50–65 years | 414/506 (82%) | |
| Race/Ethnicity | ||
| White, non-Hispanic | 984/1264 (78%) | 0.16 |
| White, Hispanic | 60/77 (78%) | |
| Black | 103/148 (70%) | |
| Asian | 63/79 (80%) | |
| Other** | 97/133 (73%) | |
| Marital Status | ||
| Married or partnered | 948/1209 (78%) | 0.01 |
| Not married or partnered | 358/491 (73%) | |
| High-Risk Status *** | ||
| Yes | 409/513 (80%) | 0.06 |
| No | 898/1188 (76%) | |
| High-Risk Household **** | ||
| Yes | 474/579 (82%) | <0.001 |
| No | 833/1122 (74%) | |
| Education | ||
| High school or less | 87/116 (75%) | 0.07 |
| College | 938/1239 (76%) | |
| Masters/advanced degree | 282/346 (82%) | |
| Occupation | ||
| Physicians/Dentists | 194/230 (84%) | 0.03 |
| Nurses | 448/576 (78%) | |
| Medical assistants/Technicians | 557/751 (74%) | |
| Therapists | 70/93 (75%) | |
| Other care providers | 38/51 (75%) | |
| Years in Patient Care | ||
| 0–5 years | 313/400 (78%) | 0.01 |
| 6–10 years | 253/342 (74%) | |
| 11–15 years | 204/270 (76%) | |
| 16–20 years | 139/199 (70%) | |
| 21+ years | 398/490 (81%) | |
| Work Setting | ||
| Outpatient | 454/569 (80%) | 0.40 |
| ICU | 21/28 (75%) | |
| Hospital | 170/219 (78%) | |
| ED | 15/21 (75%) | |
| LTCF | 3/5 (60%) | |
| Multiple settings | 626/833 (75%) | |
| Unknown | 18/26 (69%) | |
| Job Satisfaction | ||
| Dissatisfied | 58/85 (68%) | <0.001 |
| Neutral | 75/118 (64%) | |
| Satisfied | 1173/1497 (78%) | |
| Seasonal influenza vaccination in 2009–10 | ||
| Yes | 857/941 (91%) | <0.001 |
| No | 450/760 (59%) | |
| Pandemic H1N1 influenza vaccination in 2009–10 | ||
| Yes | 1137/1272 (89%) | <0.001 |
| No | 170/429 (40%) |
SWH=Scott and White Healthcare; KPNW=Kaiser Permanente Northwest; ICU=intensive care unit; ED=emergency department; LTCF=long-term care facility
includes both self-reported and health record influenza vaccinations
includes participants self-identifying as Hispanic, non-white or multiracial
self-reported diagnosis of asthma, cancer, chronic lung disease, diabetes, heart problem, immunosuppression, kidney disease, neurologic or neuromuscular disorder
living in household with pregnant woman, infant <1 year of age, adult >65 years of age, person with asthma, or person with a serious chronic health condition
On the post-season survey, 1,262 participants reported receiving the 2010–2011 influenza vaccine and 1,223 (97%) of these reported vaccinations were confirmed by electronic health record data. Of the 39 participants who reported an unconfirmed vaccination, 56% reported receiving their vaccination from SWH or KPNW; forty-four percent reported receiving their vaccine at another location, including a worksite or military vaccination program (n=13, 34%), the health department (n=3, 8%), or a pharmacy or grocery store (n=1, 3%). The concordance between self-reported and health-record-vaccination data was high (Kappa=0.87 (95% CI: 0.84–0.90)).
Among 1,262 participants who reported receiving a 2010–2011 influenza vaccine, 4% (n=50) reported a low grade fever and <1% reported lightheadedness (n=8), hives (n=1), or an allergic reaction (n=1) following vaccination. Among the 1,179 participants who reported receiving inactivated influenza vaccine, 59% (n=697) reported arm soreness, 8% (n=94) reported redness, 7% (n=78%) reported bruising, and 6% (n=75) reported swelling at the injection site. Among the 83 participants who reported receiving live attenuated, intranasal influenza vaccine, 14% (n=12) reported headache and 12% (n=10) reported cold symptoms following vaccination.
Personal protection from influenza was reported as the most important reason for vaccination, followed closely by convenience, protection of patients, protection of family and friends, and having access to free vaccine at work (for all, ≥84% of HCP rated as extremely or very relevant) (Table 2). Among the vaccinated HCP, few (<36%) described peer or employer recommendations as extremely or very relevant reasons they were vaccinated. Over half (52%) reported employer requirement for vaccination as little or not at all relevant.
Table 2.
Healthcare personnel (n=1,262) reported reasons for receiving influenza vaccine
| Relevance | |||
|---|---|---|---|
| Extremely/Very | Somewhat | A little/Not at all | |
| Protect self | 1118 (88%) | 111 (9%) | 33 (3%) |
| Easy to get vaccine at work | 1101 (87%) | 121 (10%) | 40 (3%) |
| Protect patients | 1075 (85%) | 141 (11%) | 46 (4%) |
| Protect family and friends | 1061 (85%) | 154 (12%) | 47 (3%) |
| Vaccine offered free of charge at work | 1053 (84%) | 121 (10%) | 88 (7%) |
| Avoid missing work | 992 (79%) | 154 (12%) | 115 (9%) |
| Employer recommendation | 700 (55%) | 323 (26%) | 239 (19%) |
| Most work colleagues are vaccinated | 639 (51%) | 309 (24%) | 314 (25%) |
| Employer pays for vaccination time | 632 (50%) | 228 (18%) | 400 (32%) |
| Physician or nurse recommendation | 473 (38%) | 305 (24%) | 484 (38%) |
| Work colleague recommendation | 449 (36%) | 341 (27%) | 417 (37%) |
| Employer requirement | 338 (27%) | 262 (21%) | 661 (52%) |
Concerns about vaccine safety and low perceived susceptibility to influenza were the most commonly reported barriers to vaccination among the 439 participants who reported not being vaccinated (Table 3). Thirty-percent of participants reported they did not want the H1N1 component of the vaccine and 28% reported concern about side effects. No single individual barrier was reported by more than 30% of participants. Nineteen percent (85/439) of the unvaccinated participants said influenza is not a very serious illness, and 17% (74/439) said that concern about getting the flu from the flu shot was an important reason they were not vaccinated.
Table 3.
Healthcare personnel (n=439) reported reasons for not receiving influenza vaccine
| Relevance | |||
|---|---|---|---|
| Extremely/Very | Somewhat | A little/Not at all | |
| Made a decision not to be vaccinated | 265 (60%) | 54 (12%) | 120 (27%) |
| Did not want H1N1 component of vaccine | 130 (30%) | 61 (14%) | 247 (56%) |
| Concerned about side effects | 124 (28%) | 71 (16%) | 244 (56%) |
| Flu is not a very serious illness | 85 (19%) | 105 (24%) | 248 (57%) |
| Concerned about getting the flu from the flu shot | 74 (17%) | 77 (18%) | 288 (66%) |
| Flu vaccination is not needed | 72 (16%) | 127 (29%) | 237 (55%) |
| Meant to get the vaccine but did not | 66 (15%) | 35 (8%) | 337 (77%) |
| Think flu vaccines do not work | 64 (15%) | 120 (27%) | 255 (58%) |
| Do not have contact with people who get the flu | 55 (12%) | 52 (12%) | 331 (76%) |
| Ambivalent or “on the fence” about vaccination | 53 (12%) | 87 (20%) | 298 (68%) |
| Had a severe reaction following a prior vaccination | 48 (11%) | 33 (8%) | 358 (81%) |
| Allergic to the vaccine | 29 (7%) | 15 (3%) | 394 (90%) |
| Did not know how to get a flu shot | 25 (6%) | 13 (3%) | 401 (91%) |
| Already had the flu earlier in the season | 16 (4%) | 15 (3%) | 407 (93%) |
Sixty percent (n=265) of unvaccinated participants reported they had made a conscious decision not to be vaccinated (Table 3). Among these HCP, the most commonly reported reasons for this decision were concern about the H1N1 component (40%), concerns about side effects (39%), and concerns about getting influenza from the vaccine (25%). Thirty-five percent of the 174 unvaccinated participants who did not make a conscious decision about vaccination reported that they meant to get the vaccine but did not. The second most commonly reported barrier to vaccination in this group was the belief that influenza is not a serious illness (16%) followed by concerns about side effects (12%).
Twelve percent (n=53) of the unvaccinated participants reported being ambivalent or “on the fence” about vaccination (Table 3). Reported barriers to vaccination in this group included concerns about the H1N1 component of the vaccine (47%), believing influenza is not a serious illness (43%), concerns about side effects (42%), and concerns about getting influenza from the vaccine (38%).
In response to questions about employer requirements for annual influenza vaccination, 53% (n=231) of unvaccinated participants said they would have received the vaccine if it was required for all health care personnel, 27% (n=118) said they would not have received the vaccine, and 20% (n=90) were unsure. Forty-one percent (n=179) of unvaccinated participants said they would have received the vaccine if they were required to either receive the vaccine or sign a written declination form.
DISCUSSION
In a cohort of HCP providing direct patient care from two healthcare delivery systems, vaccine coverage during the 2010–2011 season (77%) was higher than reported in other studies, but did not meet the 90% Healthy People 2020 goal. The most frequently reported reasons for vaccine acceptance were protection of self, patients, friends, and family from influenza. Concerns about vaccine safety, and the H1N1 component of the vaccine in particular, were consistently reported as barriers to vaccination in this cohort, but were reported by less than half of unvaccinated HCP. We identified HCP who made a conscious decision to decline vaccination, as well as HCP who were “on the fence” about vaccination and those who “meant to be vaccinated” but were not. Our findings suggest that unvaccinated HCP are a heterogeneous group and reasons for non-acceptance of vaccine are complex. A variety of strategies are needed to increase vaccine coverage in this group.
Both SWH and KPNW used a variety of strategies to encourage influenza vaccination during the study period, including providing vaccines free of charge, email and print media messages, peer vaccinators, walk-in flu shot clinics, and roving nurses with vaccine carts. Although both sites strongly encouraged vaccination, neither site required vaccination as a condition of employment. The coverage rate observed in this cohort was higher than previously reported rates, but still fell short of meeting the Healthy People 2020 goal of 90% coverage.[10] Several recently published studies have reported coverage rates exceeding 90% in settings where vaccination was required by the employer.[7–9]
Our reported coverage rates must be interpreted with some caution because we enrolled a voluntary sample of HCP from SWH (about 40% of eligible employees) and KPNW (about 20% of eligible employees).[18] The estimated 2010–2011 influenza vaccine coverage among all employees, based on electronic medical records and employee health records, was 71% at SWH and 64% at KPNW, suggesting that we enrolled HCP who were more likely to be vaccinated than their non-enrolled peers. Additionally, we focused our study on HCP involved in direct patient care who would be expected to have high vaccine coverage, and the reported employee health rates include HCP in non-clinical and administrative roles. We also used a combination of self-reported and health- record-confirmed vaccinations in our estimate of coverage, which may have increased our reported rates. Most previous studies of influenza vaccine coverage have relied on self-reported vaccination only.[1,3–5] Although the concordance between self-reported and health record influenza vaccinations was high in this cohort, we would have missed some vaccinated participants by relying only on one data source, especially those HCP who were vaccinated outside our delivery systems.
In a meta-analysis of 25 studies published from 1980 through 2008, Hollmeyer et al. reported that the most common reasons for influenza vaccine acceptance among HCP were self-protection, protection of patients, protection of family and friends, and convenience.[6] These same reasons were reported by vaccinated HCP in our cohort. Other predictors of influenza vaccination among HCP from the meta-analysis included older age, longer duration of employment, higher education or socio-economic status, and working as a physician.[6] We report similar predictors of vaccination in our cohort with the addition of higher job satisfaction, having a partner, and living in a high-risk household. HCP with more education had higher vaccination coverage than those with less education, but this was not a statistically significant difference.
Concerns about vaccine safety were frequently reported as barriers to vaccination in the meta-analysis and in our cohort.[6] The most commonly reported adverse reaction following inactivated influenza vaccination in adults is injection site pain (10%-64% across studies)[1]; 59% of HCP at SWH and KPNW reported arm soreness. After live, attenuated influenza vaccination, 28%-78% of adults report runny nose or nasal congestion depending on the study, 16%-44% report headache, and 15%-27% report sore throat.[1] Fourteen percent of HCP in our cohort reported headache following live attenuated vaccination and 12% reported cold symptoms, consistent with the lower range of adverse effects reported by other studies. These findings, in conjunction with numerous other published clinical and observational studies, should reassure HCP that either formulation of influenza vaccine is safe and does not have serious side effects.
Providing HCP with additional education about vaccine safety may modestly improve influenza vaccination rates.[12] This information may be especially important to HCP who are ambivalent or “on the fence” about vaccination. Furthermore, HCP are an important source of vaccine information and recommendations for their patients and it is therefore important that they have accurate information about vaccine risks and benefits.[21–23] In our cohort, 17% of unvaccinated participants falsely believed that the influenza vaccine can give you influenza, which suggests that there is still room for improvement in terms of HCP education.
Very few unvaccinated participants reported not knowing how to access vaccination, yet 35% of unvaccinated participants who did not actively decide against vaccination reported that they meant to get the vaccine but did not. Thus, it is important to maintain easy and convenient access to vaccine in the workplace to ensure that people who intend to be vaccinated are easily able to do so. Measures such as extending hours of vaccination or increasing days that flu vaccine carts are available might be a good investment of resources for health-care organizations seeking to increase uptake among HCP who said they had intended to get vaccinated but did not. Future studies looking at return on investment for such costs would be beneficial.
Our findings confirm that HCP generally accept influenza vaccination to protect themselves and people around them. Reasons for declining vaccination are less clear, but concerns about vaccine safety, low perceived susceptibility to influenza infection, and doubts about vaccine effectiveness are important barriers to vaccination. This study highlights some areas to target for improved HCP education and messaging about influenza vaccine safety and effectiveness. Targeting these concerns specifically may help organizations reach the Healthy People 2020 influenza vaccination goals. Additionally, there is growing evidence that requiring vaccination as a condition of employment can have an immediate and dramatic impact on improving vaccination rates.[7–12] Consistent with other studies, our data suggest that employer required vaccination would generally be accepted by HCP who are less willing to be vaccinated. Future research examining the cost-effectiveness of specific measures to raise vaccination rates, particularly among those who either were ambivalent about vaccination or who simply did not get around to it, will be useful for closing the gap between desired and current vaccination rates.
ACKNOWLEDGEMENTS
The authors would like to acknowledge Drs. Alicia Fry and Lisa Grohskopf for providing their feedback on an earlier version of this manuscript.
Funding for this study was supported by the Centers for Disease Control and Prevention (contract 200–2010-F-33396 to Abt Associates, Inc.). The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention, Abt Associates Inc., Kaiser Permanente Center for Health Research, or Scott and White Healthcare.
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