Workplace efforts to promote influenza vaccination among healthcare personnel and their association with uptake during the 2009 pandemic influenza A (H1N1)

Article (PDF Available)inVaccine 29(16):2978-85 · February 2011with4 Reads
DOI: 10.1016/j.vaccine.2011.01.112 · Source: PubMed
Abstract
Survey data suggest that, in a typical year, less than half U.S. healthcare personnel (HCP) are vaccinated for influenza. We measured workplace efforts to promote influenza vaccination among HCP in the U.S. and their association with seasonal and pandemic vaccination during the 2009-10 influenza season. Self-reported survey data collected in June 2010 from eligible HCP (n=1714) participating in a nationally representative, online research panel. HCP eligible for participation in the survey were those reporting as patient care providers and/or working in a healthcare setting. The survey measured workplace exposure to vaccination recommendations, vaccination requirements, on-site vaccination, reminders, and/or rewards, and being vaccinated for seasonal or H1N1 influenza. At least two-thirds of HCP were offered worksite influenza vaccination; about one half received reminders; and 10% were required to be vaccinated. Compared to HCP in other work settings, hospital employees were most (p<0.001) likely to be the subject to efforts to promote vaccination. Vaccination requirements were associated with increases in seasonal and pandemic vaccination rates of between 31 and 49% points (p<0.005). On-site vaccination was associated with increases in seasonal and pandemic vaccination of between 13 and 29% points (p<0.05). Reminders and incentives were not associated with vaccination. Our findings provide empirical support for vaccination requirements as a strategy for increasing influenza vaccination among HCP. Our findings also suggest that making influenza vaccination available to HCP at work could increase uptake and highlight the need to reach beyond hospitals in promoting vaccination among HCP.
Vaccine 29 (2011) 2978–2985
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Vaccine
journal homepage: www.elsevier.com/locate/vaccine
Workplace efforts to promote influenza vaccination among healthcare personnel
and their association with uptake during the 2009 pandemic influenza A (H1N1)
Katherine Harris
a,
, Jürgen Maurer
a
, Carla Black
b
, Gary Euler
b
, Srikanth Kadiyala
c
a
RAND Corporation, 1200 South Hayes Street, Arlington, VA, United States
b
U.S. Centers for Disease Control and Prevention, Atlanta, GA, United States
c
RAND Corporation, Santa Monica, CA, United States
article info
Article history:
Received 7 October 2010
Received in revised form 22 January 2011
Accepted 31 January 2011
Available online 18 February 2011
Keywords:
Vaccination requirement
Vaccination mandate
Healthcare personnel
Healthcare worker
Influenza vaccination
H1N1
2009 pandemic
abstract
Background: Survey data suggest that, in a typical year, less than half U.S. healthcare personnel (HCP) are
vaccinated for influenza. We measured workplace efforts to promote influenza vaccination among HCP
in the U.S. and their association with seasonal and pandemic vaccination during the 2009–10 influenza
season.
Methods: Self-reported survey data collected in June 2010 from eligible HCP (n = 1714) participating
in a nationally representative, online research panel. HCP eligible for participation in the survey were
those reporting as patient care providers and/or working in a healthcare setting. The survey measured
workplace exposure to vaccination recommendations, vaccination requirements, on-site vaccination,
reminders, and/or rewards, and being vaccinated for seasonal or H1N1 influenza.
Results: At least two-thirds of HCP were offered worksite influenza vaccination; about one half received
reminders; and 10% were required to be vaccinated. Compared to HCP in other work settings, hospital
employees were most (p < 0.001) likely to be the subject to efforts to promote vaccination. Vaccination
requirements were associated with increases in seasonal and pandemic vaccination rates of between 31
and 49% points (p < 0.005). On-site vaccination was associated with increases in seasonal and pandemic
vaccination of between 13 and 29% points (p < 0.05). Reminders and incentives were not associated with
vaccination.
Conclusions: Our findings provide empirical support for vaccination requirements as a strategy for increas-
ing influenza vaccination among HCP. Our findings also suggest that making influenza vaccination
available to HCP at work could increase uptake and highlight the need to reach beyond hospitals in
promoting vaccination among HCP.
© 2011 Elsevier Ltd. All rights reserved.
1. Introduction
Influenza is a leading cause of illness, death, and lost pro-
ductivity in the United States [1–4]. During a typical season,
influenza-related morbidity and mortality is concentrated among
the elderly, children less than two years of age, and others with
weakened immune systems [1,2,5–7]. During the recent pandemic,
however, the burden of influenza was heaviest among children
and young and middle-aged adults who lacked immunity to the
newly circulating 2009 influenza A (H1N1) (2009 H1N1) virus [8].
Influenza vaccination is the most effective way to prevent the
transmission of influenza [9,10]. Public health officials stress the
importance of high vaccination levels among healthcare personnel
(HCP) [11]. Vaccinating HCP can reduce the iatrogenic transmission
of influenza virus to patients who are at elevated risk of influenza
Corresponding author. Tel.: +1 703 413 1100x5466.
E-mail address: kharris@rand.org (K. Harris).
and influenza complications [7,12]. In addition, vaccinating HCP can
also reduce influenza-related absenteeism, ensuring the capacity
of the healthcare system to meet elevated demand for healthcare
during influenza outbreaks [13]. These considerations motivate
long-standing federal recommendations that all HCP be vaccinated
[14], accreditation standards adopted by the Joint Commission on
Accreditation of Healthcare Organizations requiring hospitals and
long-term care facilities to offer influenza vaccine to their staff [15],
and the high priority placed on vaccinating HCP as early as possible
during the 2009 H1N1 pandemic [16].
National survey data suggest that for most of the past decade,
less than half of all HCP received annual influenza vaccination
[17]. Even with unprecedented levels of public outreach and media
attention to influenza-related issues during the recent pandemic,
only 62% of HCP were vaccinated for seasonal influenza and 37 for
pandemic influenza as of January 2010 [18].
The perception that voluntary vaccination efforts are insuf-
ficient to generate substantial increases in uptake of influenza
vaccination among HCP has fueled calls for making influenza
0264-410X/$ see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.vaccine.2011.01.112
K. Harris et al. / Vaccine 29 (2011) 2978–2985 2979
vaccination of HCP mandatory [19–22]. As of 2010, at least 58
health systems, free-standing hospitals and medical practices
across the U.S. have voluntarily required that their employees be
vaccinated annually for influenza or face consequences, such as
face-mask requirements, reassignment to non-patient care duties,
or dismissal [6,23]. Case studies and testimonials based on the
experiences of these institutions suggest that such requirements
can be highly effective in increasing uptake [6,23].
To date, however, there exist no broadly generalizable data on
the prevalence of efforts to promote influenza vaccination among
HCP and their effectiveness in increasing vaccination. To improve
knowledge in this area, we present data from a recent national sur-
vey of HCP describing a broad range of efforts to promote influenza
vaccination and their cross-sectional associations with uptake of
seasonal and H1N1 pandemic influenza vaccine during the 2009–10
influenza season.
2. Methods
2.1. Data source
This study presents self-reported survey data collected dur-
ing the June wave of a monthly survey effort funded by the
Centers for Disease Control and Prevention to monitor uptake
of influenza vaccines by HCP during the 2009 H1N1 pandemic.
The data were collected between June 1 and June 30, 2010 and
comprise a sample of self-identified HCP drawn from a nation-
ally representative, online research panel developed and operated
by Knowledge Networks (KN), Inc. The KN panel contains about
40,000 U.S. households who are randomly selected using both
telephone- and address-based sampling methods, in order to
ensure coverage of cell-phone only households in the U.S. Adults
in selected households are invited by telephone or mail to partici-
pate in the panel. KN provides households lacking Internet access
at the time of recruitment with required hardware and training
to access the Internet and an Internet service connection. Others
participate using their own computers and Internet connections.
Panelists access surveys online using a unique username and pass-
word, and receive emails three to four times a month inviting
them to participate in surveys. More information about the panel
design can be obtained at http://www.knowledgenetworks.com/
ganp/docs/Knowledge%20Networks%20Methodology.pdf.
Eligibility for the HCP survey was based on responses to a
screening questionnaire administered upon recruitment into the
KN panel. The screening questionnaire asks panelists to describe
their current occupational characteristics and work setting based
on the Standard Occupational Classification (SOC) System [24] and
the North American Industry Classification System (NAICS) [25].
Panelists were eligible for inclusion in our study if they reported
(1) working as a medical doctor, health technologist, healthcare
support staff, or other health practitioner or (2) working in a hospi-
tal, ambulatory care setting, nursing home, residential care facility
or other health-related setting based on corresponding occupation
or industry codes. A total of 2001 or 73.1% of sampled KN pan-
elists eligible for participation in the survey responded to the June
survey.
To increase the specificity of our analyses, we asked detailed
questions about respondents’ current occupation and work set-
ting and whether respondents’ work involved “hands-on care of
patients” during the last twelve months. Consistent with definitions
of HCP in other national data sources [18], the restricted analytic
sample included only those who report work in a healthcare-
related setting or work involving “hands-on care of patients”
(n = 1798). We further dropped respondents with missing data on
their occupation or work setting (33 deletions) or any of the other
Table 1
Unweighted sample sizes and weighted prevalence of U.S. healthcare
personnel—Knowledge Networks, June 2010 (n = 1714).
Characteristics Unweighted n Weighted % (95%-CI)
Combined sample 1714 100.0
Work setting
Hospital 715 36.3 (32.4,40.2)
Ambulatory, outpatient, clinic 455 23.8 (20.5,27.0)
Long term care 322 25.7 (21.7,29.6)
Other 222 14.2 (11.2,17.2)
Occupation
MD, NP, PA, or dentist 114 5.6 (4.0,7.1)
Nurse 460 21.4 (18.1,24.7)
Allied health professional 587 34.9 (31.0,38.7)
Administration, management 302 16.6 (13.6,19.5)
Non-clinical support or other 251 21.6 (17.7,25.5)
Patient contact
Provides hands-on patient care 1126 65.5 (61.5,69.5)
Work around seriously ill patients 496 25.5 (22.1,29.0)
Contact with influenza patients 890 51.6 (47.5,55.8)
survey items used in our analysis (51 deletions), which resulted in
a final analytic sample of 1714 HCP.
2.2. Measures
The survey measured being subject to employer efforts to (1)
promote influenza vaccination through voluntary means includ-
ing advice and information about vaccination, recommendations
to be vaccinated issued via letters, emails, and phone calls, and
rewards for being vaccinated, (2) make vaccination more conve-
nient by offering it in the workplace, and (3) require vaccination
with and without penalties for non-compliance, such as reassign-
ment to a different work location or being terminated. The survey
measured self-reported uptake of seasonal influenza vaccination
from August 2009 through the interview date and uptake of pan-
demic influenza vaccine from October 2009 through the interview
date. Subgroups of HCP were formed based on questions about their
occupation, work setting, involvement in hands-on patient care,
contact with seriously ill patients, and contact with flu patients
and patients with flu-like symptoms.
2.3. Analysis
Our final analytic sample (see Table 1) is described in terms
of work setting, occupation and patient care as well as selected
respondent characteristics such as race and ethnicity, gender and
existence of personal health risk factors or household contacts
that imply an influenza vaccination recommendation for reasons
other than the respondents’ status as a health care worker [14].
Unadjusted estimates of the (1) prevalence of employer-based vac-
cination policies and programs for seasonal and H1N1 influenza and
(2) uptake of seasonal and H1N1 influenza vaccines are presented
both in aggregate as well as by vaccination policy, patient con-
tact, work setting, and occupation. Estimates of the strength of the
association between employer-based policies and programs and
the uptake of influenza vaccines were derived from multivariable
linear probability models controlling for observable factors influ-
encing the uptake of both pandemic and seasonal vaccine such as
occupation, work setting, basic demographics, and being recom-
mended for influenza vaccination for reasons other than being an
HCP (i.e., on the basis of age, health status, and personal contacts).
All estimates were weighted to reflect selected demographic
and geographic characteristics of HCP in the U.S. population as
obtained from the most current monthly Current Population Sur-
vey (CPS) [26] and occupational characteristics measured in the
KN screening questionnaire. Statistical analyses were conducted
using STATA SE 10.1 (StataCorp, College Station, TX) and adjusted
2980 K. Harris et al. / Vaccine 29 (2011) 2978–2985
Wald tests were used to assess statistical significance of group
differences. The RAND Corporation’s Institutional Reviewed Board
approved the study design and survey protocols.
3. Results
Overall, 10.5% of HCP reported that their employer required
seasonal vaccination during the 2009–10 season (Table 2a). In
about half of these instances, HCP were subject to a penalty for
non-compliance, including requirements to wear face masks, reas-
signments to different work locations or job termination. At the
same time, 63.5% of HCP reported that their employer recom-
mended seasonal influenza vaccination and 71.5% of HCP were
offered seasonal vaccination onsite during the 2009–10 influenza
season. In addition, 47.6% of HCP received a postcard, letter, email or
phone call reminding them to get vaccinated for seasonal influenza.
Receipts of vaccination rewards appear to be fairly uncommon;
only 4.7% of HCP worked for an employer offering an incentive for
getting a seasonal influenza vaccination.
Being subject to employer-sponsored policies and programs
to promote seasonal vaccination varied widely across work set-
tings. Being subject to both vaccination recommendations and
requirements, with and without penalties for non-compliance, was
significantly more prevalent in hospital settings. Moreover, 91.7%
of HCP working in hospitals were offered seasonal vaccine at work,
compared to roughly 60% of HCP working in non-hospital settings.
Likewise, the probability of receiving a reminder for seasonal vac-
cination was twice as high among HCP working in hospital settings
compared to those working in non-hospital settings. While expo-
sure to policies and programs to promote seasonal vaccination also
varied by occupation, supplementary multivariable analysis (not
shown) suggests that this variation is explained, in large measure,
by work setting. The prevalence of workplace efforts to promote
pandemic vaccination was somewhat lower than that for seasonal
influenza, but otherwise displayed a very similar pattern (i.e., the
most substantive efforts to promote pandemic vaccination were
made by hospitals) (Table 2b).
Sixty-one percent of HCP were vaccinated for seasonal influenza
by June 2010, compared to only 42.9% vaccinated for H1N1, likely
reflecting the relatively late arrival of H1N1 vaccine in October of
2009 after the peak of the pandemic had passed (Table 3) [27]. Rates
of both seasonal and pandemic influenza vaccination were strongly
associated (p < 0.001) with employer-based policies and programs,
with the exception of vaccination rewards. Vaccination rates for
both types of influenza were significantly higher (p < 0.001) among
HCP who cared for seriously ill patients or had regular contact with
patients with influenza. Vaccination rates varied within work set-
ting and occupational categories, with highest rates among those
working in hospitals and among the combined category of physi-
cians, physician’s assistants, nurse practitioners, and dentists.
Table 4 shows the percentage point change in the probability
of vaccine uptake associated with the presence of a workplace
vaccination effort or occupational characteristic relative to its
absence, holding other variables constant. Of the six employer poli-
cies considered, vaccination requirements displayed the strongest
independent association with both seasonal and pandemic vacci-
nation. Requirements with penalties were associated with a 39.7%
point increase (p < 0.001) in the probability of seasonal vaccina-
tion and a 49.0% point increase in the probability of vaccination for
pandemic influenza (p = <0.001) compared to HCP who were nei-
ther required to be vaccinated or recommended for vaccination.
Requirements without penalties were associated with a 31.5% point
increase (p < 0.001) in the probability of seasonal vaccination and
a 30.5% point increase in the probability of pandemic vaccination
(p < 0.05). Vaccination recommendations, by contrast, were asso-
ciated with an increase in the probability of seasonal vaccination
of only 9.2% points (not significant) and 19.5% points (p < 0.001) for
pandemic vaccination. Offering vaccination at work was associated
with a 28.8% point increase (p < 0.001) in the probability of seasonal
vaccination and a 13.4% point increase (p < 0.05) in pandemic vac-
cination. Receipt of vaccination reminders and rewards was not
significantly associated with increased vaccination for either sea-
sonal or pandemic influenza in a multivariable analysis.
Working around seriously ill patients and having contact
with influenza patients were associated with 8.6 and 7.2% point
increases (p < 0.05) in the probability of seasonal vaccination,
respectively, even after controlling for policies and programs to
promote vaccination. Patient contact was not associated with pan-
demic vaccination when controlling for other characteristics of
HCP.
After controlling for vaccination policies and programs, working
in an ambulatory care settings was associated with higher seasonal
vaccination rates compared to working in a hospital (the referent
category) (p < 0.01). Otherwise, work setting was not associated
with either seasonal or pandemic vaccination in the presence of
control variables.
Occupation was not independently associated with seasonal
vaccination after controlling for specific policies, programs, and
HCP characteristics. However, support staff and other types of
HCP were significantly less likely to be vaccinated for pandemic
influenza compared to front-line personnel, including physicians,
physicians assistants, nurse practitioners, and dentists (the referent
category) (p < 0.05).
4. Comment
Overall, our results indicate that employers used a variety of
approaches to promote influenza vaccination among HCP during
the 2009–10 influenza season. Efforts included worksite vaccina-
tion, vaccination reminders, recommendations, and requirements
to be vaccinated, with or without penalties for non-compliance. At
least two-thirds of HCP worked for employers who offered work-
site vaccination, and about one half of HCP received reminders
from their employer to be vaccinated. By contrast, only 10% of
HCP worked for an employer who required vaccination, with
or without penalties for noncompliance. Compared to HCP in
other work settings, hospital employees were most likely to be
subject to employer vaccination policies such as on-site vacci-
nation programs, vaccination recommendations, and vaccination
requirements.
Among the worksite policies studied, vaccination requirements
were most strongly associated with vaccination for both seasonal
and pandemic influenza. We found that employer requirements
backed by penalties were more strongly associated with vaccina-
tion than requirements without penalties. This finding is consistent
with case studies reporting universal, or close to universal, vacci-
nation rates among hospital employees who face the prospect of
termination or other strict penalties [28]. Published case reports
are less conclusive about the effect of requirements paired with
less strict penalties, such as having to sign a declination form
[29–31].
Our findings suggest that even without penalties for non-
compliance, a policy of requiring vaccination is associated with
sharply higher rates of compliance than that associated with more
commonly used recommendations, such as recommendations and
reminders alone or in combination. Our findings also suggest that
the convenience of on-site vaccination is very important. We found
that HCP offered vaccination at work were nearly 30% more likely
to be vaccinated for seasonal influenza and almost 15% more likely
to be vaccinated for pandemic influenza compared to those not
K. Harris et al. / Vaccine 29 (2011) 2978–2985 2981
Table 2a
Self-reported employer-based seasonal influenza vaccination requirements, recommendations and other workplace programs and policies by work setting, occupation, and vaccination type during the 2009–10 influenza season
(n = 1714).
Employee characteristic Requirements and recommendations Other workplace policies and programs
Vaccination required
with penalty
Vaccination required
without penalty
Vaccination recommended Vaccination offered at
worksite
Vaccination reminders issued Vaccination rewards offered
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Overall 5.8 (4.1,7.6) 4.7 (2.8,6.6) 63.5 (59.3,67.6) 71.5 (67.6,75.4) 47.6 (43.5,51.7) 4.7 (2.8,6.6)
Patient contact
Provides hands-on care 5.9 (4.0,7.9) 0.880 5.3 (2.7,7.8) 0.379 63.3 (58.2,68.4) 0.909 70.5 (65.7,75.3) 0.468 47.8 (42.8,52.8) 0.908 4.8 (2.4,7.2) 0
.935
Cares for seriously ill 14.0 (9.1,18.9) <0.001 6.3 (2.5,10.2)
b
0.299 69.8 (62.3,77.2) 0.071 91.5 (87.3,95.7) <0.001 63.9 (56.3,71.5) <0.001 5.0 (2.6,7.4) 0.827
Contact with influenza
patients
7.1 (4.6,9.6) 0.177 5.3 (2.7,7.8) 0.553 69.7 (64.3,75.2) 0.002 80.9 (76.5,85.2) <0.001 50.8 (45.0,56.5) 0.120 4.5 (2.2,6.7) 0.781
Setting
Hospital 12.9 (8.4,17.3) <0.001 4.0 (2.3,5.7) 0.784 72.4 (65.8,79.1) 0.004 91.7 (87.1,96.4) <0.001 68.9 (62.2,75.6) <0.001 6.9 (3.2,10.5) <0.041
Ambulatory, outpatient 2.3 (1.0,3.6) 4.1 (1.4,6.9)
b
63.3 (56.2,70.3) 61.2 (54.1,68.4) 37.5 (30.0,45.1) 2.6 (0.3,4.9)
b
Long term care 2.0 (0.4,3.5)
b
6.2 (0.7,11.8)
b
58.3 (49.0,67.6) 60.9 (51.8,70.1) 35.8 (27.1,44.5) 5.9 (1.3,10.5)
b
Other 0.8 (0.0,1.8)
b
4.7 (0.0,10.3)
b
50.1 (38.6,61.6) 56.2 (44.8,67.6) 31.6 (21.6,41.7) 0.5 (0.0,1.1)
b
Occupation
MD, NP, PA, or dentist 3.4 (0.2,6.6)
b
0.163 12.1 (0.0,24.4)
b
0.214 60.3 (46.1,74.5) 0.048 72.1 (59.8,84.4) <0.001 38.3 (25.5,51.2) 0.060
c
0.207
Nurse 8.3 (4.2,12.4) 3.0 (0.8,5.2)
b
73.3 (65.0,81.6) 88.4 (82.7,94.2) 54.8 (46.0,63.6) 3.5 (1.3,5.8)
b
Allied health professional 5.4 (2.9,7.8) 4.0 (1.4,6.7)
b
61.1 (54.6,67.7) 61.6 (55.1,68.1) 46.1 (39.5,52.7) 3.5 (1.7,5.4)
Admin and management 8.3 (1.5,15.1)
b
3.7 (1.3,6.0)
b
67.6 (58.1,77.0) 80.2 (72.5,87.9) 54.7 (45.1,64.3) 6.1 (0.5,11.7)
b
Support staff and other 2.9 (0.5,5.2)
b
6.3 (0.1,12.4)
b
55.1 (44.2,65.9) 63.9 (53.3,74.5) 40.0 (29.9,50.0) 8.0 (1.5,14.4)
b
a
p-Values indicate statistical significance of differences in vaccination rates across groups defined by employee characteristics.
b
Relative standard error larger than 30%.
c
Sample too small to calculate.
2982 K. Harris et al. / Vaccine 29 (2011) 2978–2985
Table 2b
Self-reported employer-based H1N1 pandemic influenza vaccination requirements, recommendations and other workplace programs and policies by work setting, occupation, and vaccination type during the 2009–10 influenza
season (n = 1714).
Employee characteristic Requirements and recommendations Other workplace policies and programs
Vaccination required
with penalty
Vaccination required
without penalty
Vaccination recommended Vaccination offered at
worksite
Vaccination reminders issued Vaccination rewards offered
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Weighted %
(95-CI)
p-Value
a
Overall 4.9 (3.0,6.7) 2.8 (1.4,4.3) 62.5 (58.3,66.7) 63.2 (59.1,67.3) 44.6 (40.5,48.6) 3.6 (1.8,5.4)
Patient contact
Provides hands-on care 4.1 (2.5,5.7) 0.305 3.0 (1.1,4.9)
b
0.758 64.7 (59.7,69.6) 0.166 63.7 (58.7,68.6) 0.761 45.3 (40.4,50.3) 0.600 2.8 (1.1,4.5) 0.215
Cares for seriously ill 10.5 (6.4,14.6) <0.001 2.8 (1.0,4.5)
b
0.924 73.9 (66.9,80.8) 0.001 87.0 (82.2,91.8) <0.001 60.2 (52.6,67.8) <0.001 3.5 (1.7,5.3) 0.919
In contact with flu patients 6.0 (3.3,8.7) 0.231 2.8 (1.3,4.3) 0.959 68.4 (62.9,73.9) 0.004 69.2 (63.7,74.7) 0.003 45.0 (39.4,50.7) 0.824 3.2 (1.2,5.3)
b
0.664
Setting
Hospital 9.2 (5.3,13.1) <0.001 2.5 (1.1,3.9) 0.628 78.6 (72.6,84.6) <0.001 89.8 (84.6,95.0) <0.001 68.4 (61.7,75.1) <0.001 6.3 (2.7,9.9) 0.034
Ambulatory, outpatient 5.1 (0.5,9.8)
b
2.0 (0.8,3.3)
b
54.6 (47.0,62.1) 49.6 (42.1,57.1) 33.5 (26.3,40.6) 1.3 (0.0,3.1)
b
Long term care 1.0 (0.1,1.9)
b
3.0 (0.0,7.1)
b
54.9 (45.7,64.2) 52.8 (43.6,62.0) 32.6 (24.0,41.1) 3.8 (0.0,8.0)
b
Other 0.4 (0.0,1.1)
b
4.8 (0.0,10.3)
b
48.4 (37.0,59.8) 37.1 (26.4,47.7) 23.9 (15.0,32.7) 0.2 (0.0,0.6)
b
Occupation
MD, PA, NP, or dentist 2.1 (0.0,4.8)
b
0.016 5.1 (0.8,9.3)
b
0.588 61.3 (47.9,74.8) <0.001 64.6 (51.7,77.5) <0.001 38.2 (25.4,51.0) 0.056
c
0.150
Nurse 3.7 (2.0,5.3) 1.7 (0.0,3.6)
b
78.7 (71.5,85.9) 81.6 (75.3,88.0) 51.3 (42.6,59.9) 2.6 (0.8,4.4)
b
Allied health professional 4.9 (2.3,7.5) 2.6 (0.5,4.6)
b
60.2 (53.7,66.7) 53.2 (46.5,59.8) 42.6 (36.1,49.1) 2.2 (0.8,3.7)
b
Admin and management 10.7 (2.1,19.3)
b
2.4 (0.5,4.3)
b
66.3 (56.7,75.9) 68.1 (58.8,77.3) 52.4 (42.8,62.0) 4.4 (0.0,9.5)
b
Support staff and other 2.3 (0.4,4.2)
b
4.1 (0.0,9.3)
b
47.6 (37.0,58.1) 57.1 (46.4,67.9) 36.6 (27.0,46.3) 7.2 (0.8,13.5)
b
a
p-Values indicate statistical significance of differences in vaccination rates across groups defined by employee characteristics.
b
Relative standard error larger than 30%.
c
Sample too small to calculate.
K. Harris et al. / Vaccine 29 (2011) 2978–2985 2983
Table 3
Uptake of influenza vaccine by vaccine type and worker characteristic (n = 1714).
Employee characteristic Seasonal influenza vaccination 2009 H1N1 influenza vaccination
Weighted % (95-CI) p-Value
a
Weighted % (95-CI) p-Value
a
Overall 61.0 (56.9,65.1) 42.9 (38.9,46.9)
Requirements and recommendations
Requirement with penalty 98.3 (96.0,100.0) <0.001 86.9 (68.4,100.0) <0.001
Requirement without penalty 88.0 (68.7,100.0) 63.7 (35.0,92.3)
Recommendation 66.2 (61.7,70.7) 50.7 (45.7,55.6)
Neither 35.2 (26.5,44.0) 17.3 (11.7,22.9)
Other workplace policies and programs
Offered vaccination onsite
Yes 72.9 (68.7,77.1) <0.001 54.6 (49.5,59.6) <0.001
No 31.3 (24.1,38.5) 22.8 (16.9,28.7)
Received vaccination reminders
Yes 74.2 (69.3,79.1) <0.001 56.8 (51.0,62.6) <0.001
No 49.1 (43.0,55.1) 31.7 (26.3,37.1)
Offered rewards for vaccination
Yes 62.0 (40.6,83.5) 0.925 43.0 (20.1,65.9) 0.992
No 61.0 (56.8,65.1) 42.9 (20.1,65.9)
Patient contact
Provides hands-on care
Yes 62.1 (57.1,67.1) 0.494 44.8 (39.8,49.7) 0.213
No 59.1 (52.0,66.1) 39.3 (32.5,46.2)
Cares for seriously ill
Yes 78.8 (72.8,84.8) <0.001 61.7 (54.5,69.0) <0.001
No 54.9 (50.0,59.9) 36.4 (31.9,41.0)
In contact with flu patients
Yes 70.3 (65.1,75.5) <0.001 50.3 (44.6,56.1) <0.001
No 51.2 (45.2,57.1) 34.9 (29.5,40.4)
Setting
Hospital 68.5 (62.2,74.9) 0.008 55.4 (48.9,62.0) <0.001
Ambulatory, outpatient, clinic 63.6 (56.5,70.7) 35.4 (28.8,41.9)
Long term care 54.5 (45.2,63.8) 36.1 (27.5,44.7)
Other 49.3 (37.8,60.8) 35.8 (24.9,46.7)
Occupation
MD, PA, NP, or dentist 71.8 (59.8,83.9) 0.021 53.9 (40.0,67.8) 0.002
Nurse 69.1 (61.1,77.0) 55.1 (46.6,63.5)
Allied health professional 58.1 (51.5,64.6) 40.6 (34.3,46.9)
Administration, management 65.8 (56.8,74.8) 43.1 (33.6,52.6)
Support staff and other 51.5 (40.8,62.2) 31.5 (22.3,40.7)
a
p-Values indicate statistical significance of differences in vaccination rates across groups defined by employee characteristics.
offered vaccination at work. This finding implies that offering
vaccination in work settings where it is not currently offered to
employees may serve to “jump start” efforts to increase vaccination
rates among HCP.
Although occupation appears unassociated with seasonal vacci-
nation, we found that, even controlling for other factors, physicians
and other front-line personnel were substantially more likely to be
vaccinated for pandemic influenza compared to their counterparts
who hold technical, operational, or administrative roles in health-
care delivery organizations. This finding may reflect the fact that
H1N1 vaccination was recommended for persons involved direct
patient care [16], but may also suggest that the skepticism regard-
ing the need for pandemic vaccination held by many adults in the
general population [32,33] is also prevalent among HCPs who are
not involved in direct patient care.
Our findings indicate that hospitals played a leading role in
organized efforts to vaccinate HCP during the 2009–10 influenza
vaccination season. Compared to doctors’ offices and other care set-
tings, hospitals were more likely to have implemented each of the
six promotion strategies studied, including offering vaccination on-
site and requiring vaccination with penalties for non-compliance.
Both seasonal and pandemic vaccination was substantially higher
among hospital employees than among HCP working in other set-
tings. Once we controlled for employer-based vaccination policies,
however, neither working in a hospital nor direct involvement in
patient care was independently associated with an increased prob-
ability of vaccination for either type of influenza. This suggests that
vaccination policies and programs, more than the settings in which
they are implemented, are the determining factor in a healthcare
worker’s decision to be vaccinated for influenza.
To our knowledge, our study is the first comprehensive effort
to collect nationally representative data describing uptake of
influenza vaccine by HCP and their relationship between influenza
vaccination and specific employer-based efforts to promote vac-
cination and occupational characteristics. Our findings are subject
to three important limitations. First, the representativeness of the
sample is uncertain. In the absence of a practical and affordable
method of drawing a population-based sample of HCP, we recruited
a sample comprised primarily of self-identified HCP who agreed in
advance to participate in our surveys and received a small payment
in exchange for doing so. Although we weighted the respondents
to be nationally representative based demographic and occupa-
tional characteristics of HCP as measured in the CPS, this may not
necessarily account for unmeasured differences between the U.S.
population of HCP and those in our sample.
Second, our data provide limited insight into the causal rela-
tionship between vaccination policies and programs and vaccine
uptake. Our data suggest strong associations between the strictness
and comprehensiveness of policies and subsequent vaccination.
However, it may be the case that HCPs who have a clear under-
standing of influenza vaccine’s benefits in health care settings are
more likely to work for employers with more stringent policies.
Third, our study indicates that there is a clear relationship
between workplace vaccination requirements—with or without
penalties for non-compliance—and HCP vaccination rates. Yet, our
sample was not large enough to provide reliable information about
2984 K. Harris et al. / Vaccine 29 (2011) 2978–2985
Table 4
Estimated
a
percentage point change in the probably of influenza vaccination associated with changes in employee characteristics by vaccine type (n = 1714).
Employee characteristics Seasonal influenza vaccination 2009 H1N1 influenza vaccination
Percentage point change in
probability of uptake (95% CI)
p-Value
b
Percentage point change in
probability of uptake (95% CI)
p-Value
b
Requirements and recommendations
No requirement or recommendation
c
c
Requirement with penalty 39.7 (25.8,53.6) <0.001 49.0 (28.0,70.0) <0.001
Requirement without penalty 31.5 (14.4,48.7) <0.001 30.5 (4.1,56.9) 0.024
Recommendation 9.2 (3.2,21.6) 0.146 19.5 (9.4,29.6) <0.001
Other workplace policies and programs
Offered vaccination onsite 28.8 (17.2,40.5) <0.001 13.4 (3.0,23.8) 0.012
Received vaccination reminders 6.7 (1.6,15.0) 0.112 5.5 (3.8,14.9) 0.246
Offered rewards for vaccination 3.7 (23.7,16.3) 0.719 3.4 (22.8,16.0) 0.733
Patient contact
Provides hands-on patient care 2.4 (11.8,7.0) 0.616 3.4 (12.6,5.9) 0.476
Work around seriously ill patients 8.6 (0.3,16.9) 0.042 9.2 (0.4,18.7) 0.06
Contact with influenza patients 7.2 (0.1,14.3) 0.048 5.2 (2.5,12.8) 0.186
Setting
Hospital
c
c
Ambulatory, outpatient, clinic 13.1 (3.6,22.6) 0.007 3.7 (15.2,7.7) 0.523
Long term care 6.9 (3.2,16.9) 0.181 1.9 (9.6,13.4) 0.747
Other 5.9 (6.7,18.6) 0.359 6.0 (7.5,19.6) 0.384
Occupation
MD, PA, NP, or dentist
c
c
Nurse 1.4 (14.9,12.1) 0.841 5.8 (22.1,10.6) 0.489
Allied health professional 4.1 (16.7,8.4) 0.516 12.9 (27.7,1.9) 0.088
Administration, management 3.5 (19.0,11.9) 0.654 15.7 (33.0,1.5) 0.074
Support staff and other 8.6 (23.5,6.3) 0.256 20.4 (37.4,3.5) 0.018
a
Estimates based on linear regressions that include controls for gender, race, and being recommended for influenza vaccination based on age, health status, and personal
contacts and characteristics listed in the table. The models are also controlled for all other variables in the table.
b
p-Values indicate statistical significance of individual coefficient estimates.
c
Reference category.
the prevalence or nature of penalties that employers imposed on
HCP who choose to remain unvaccinated and on differences in vac-
cination rates associated with different types of requirements.
In summary, our findings suggest a strong relationship between
uptake and exposure to work-based efforts to promote influenza
vaccination. This relationship appeared to be particularly strong
when HCP are subject to vaccination requirements paired with
penalties for non-compliance. As such, our findings provide
empirical support for vaccination requirements as a strategy for
achieving substantial increases in influenza vaccination among
HCP. Although hospital employees, regardless of occupation, were
most likely to be vaccinated, work setting was less important
than the specific programs employed in the workplace. This find-
ing highlights the potential benefits of implementing strategies to
promote influenza vaccination among HCP working in any health-
care setting, particularly those that are directly involved in patient
care.
Acknowledgement
This work was performed under contract with the U.S. Centers
for Disease Control and Prevention. The authors have no specific
financial interests, relationships, or affiliations that are relevant to
the topic of influenza vaccination of healthcare personnel that con-
stitute conflicts of interest. Dr. Jurgen Maurer analyzed the survey
data presented in this manuscript. The authors are grateful for help-
ful comments from Arthur Kellermann and James Singleton and
programming support from Rick Li.
References
[1] Centers for Disease Control and Prevention. Estimates of deaths associated with
seasonal influenza—United States, 1976–2007. MMWR Morb Mortal Wkly Rep
2010;59(33):1057–62.
[2] Thompson WW, Shay DK, Weintraub E, Brammer L, Bridges CB, Cox
NJ, et al. Influenza-associated hospitalizations in the United States. JAMA
2004;292(11):1333–40.
[3] Nichol KL, Wuorenma J, von Sternberg T. Benefits of influenza vaccina-
tion for low-, intermediate-, and high-risk senior citizens. Arch Intern Med
1998;158(16):1769–76.
[4] Mullooly JP, Bennett MD, Hornbrook MC, Barker WH, Williams WW, Patriarca
PA, et al. Influenza vaccination programs for elderly persons: cost-effectiveness
in a health maintenance organization. Ann Intern Med 1994;121(12):947–52.
[5] Mullooly JP, Bridges CB, Thompson WW, Chen J, Weintraub E, Jackson LA,
et al. Influenza- and RSV-associated hospitalizations among adults. Vaccine
2007;25(5):846–55.
[6] Immunization Action Coalition. Honor roll for patient safety: manda-
tory influenza vaccination for healthcare workers; 2010. Available from:
http://www.immunize.org/laws/influenzahcw.asp [cited 14.04.10].
[7] Salgado CD, Farr BM, Hall KK, Hayden FG. Influenza in the acute hospital setting.
Lancet Infect Dis 2002;2(3):145–55.
[8] U.S. Centers for Disease Control and Prevention. CDC estimates of 2009
H1N1 influenza cases, hospitalizations and deaths in the United States,
April 2009–March 13, 2010; 2010. Available from: http://www.cdc.gov/
h1n1flu/estimates/April
March 13.htm [4.09.10].
[9] Nichol KL, Treanor JJ. Vaccines for seasonal and pandemic influenza. J Infect Dis
2006;194(Suppl. 2):S111–8.
[10] Cox NJ, Subbarao K. Influenza. Lancet 1999;354(9186):1277–82.
[11] Centers for Disease Control and Prevention. Influenza vaccination of health-
care personnel: recommendations of the healthcare infection control practices
advisory committee (HICPAC) and the advisory committee on immunization
practices (ACIP). MMWR Morb Mortal Wkly Rep 2006;55(RR-2).
[12] Horcajada JP, Pumarola T, Martínez JA, Tapias G, Bayas JM, de la Prada M, et al. A
nosocomial outbreak of influenza during a period without influenza epidemic
activity. Eur Respir J 2003;21(2):303–7.
[13] Sartor C, Zandotti C, Romain F, Jacomo V, Simon S, Atlan-Gepner C, et al. Dis-
ruption of services in an internal medicine unit due to a nosocomial influenza
outbreak. Infect Control Hosp Epidemiol 2002;23(10):615–9.
[14] Fiore AE, Uyeki TM, Broder K, Finelli L, Euler GL, Singleton JA, et al. Prevention
and control of seasonal influenza with vaccines: recommendations of the Advi-
sory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm Rep
2009;58(RR-8):1–52.
[15] AARC. JCAHO releases 2007 patient safety goals, issues influenza con-
trol standard. In: In the news; 2006. Available from: http://www.aarc.org/
headlines/jcaho
2007 goals.cfm.
[16] Use of influenza A (H1N1) 2009 monovalent vaccine: recommendations of the
Advisory Committee on Immunization Practices (ACIP), 2009. MMWR Recomm
Rep 2009;58(RR-10):1–8.
[17] Caban-Martinez AJ, Lee DJ, Davila EP, LeBlanc WG, Arheart KL, McCollister KE,
et al. Sustained low influenza vaccination rates in US healthcare workers. Prev
Med 2010;50(4):210–2.
[18] Center for Disease Control and Prevention. Interim results: influenza A (H1N1)
2009 monovalent and seasonal influenza vaccination coverage among health-
K. Harris et al. / Vaccine 29 (2011) 2978–2985 2985
care personnel—United States, August 2009–January 2010. MMWR Morb
Mortal Wkly Rep 2010;12:357–84.
[19] They should know better. In: The New York times; 2010 [New York, NY].
[20] Poland GA, Tosh P, Jacobson RM. Requiring influenza vaccination for health care
workers: seven truths we must accept. Vaccine 2005;23(17–18):2251–5.
[21] Infectious Disease Society of America and Society for Healthcare Epidemi-
ology of America. Nation’s leading infectious diseases experts call for
mandatory flu vaccine for all healthcare personnel; 2010. Available from:
http://www.idsociety.org/Content.aspx?id=16980.
[22] American College of Physicians. American college of physicians recom-
mends flu vaccination for health care workers; 2007. Available from:
http://www.acponline.org/pressroom/hcw.htm.
[23] National Influenza Vaccine Summit. Prevent Influenza Now!. Available from:
http://www.influenzasummit.org/profs
workers.asp [cited 09.04.09].
[24] U.S. Bureau of Labor Statistics. Standard occupational classification; 2010.
http://www.bls.gov/soc/ [accessed 14.10.10].
[25] U.S. Census Bureau. North American industry classification system (NAICS);
2010. http://www.census.gov/eos/www/naics/ [accessed 14.10.10].
[26] U.S. Census Bureau. U.S. interim projections by age, sex, race, and hispanic
origin: 2000–2050; 2004. Available from: http://www.census.gov/population/
www/projections/usinterimproj/.
[27] Update on influenza A (H1N1) 2009 monovalent vaccines. MMWR Morb Mortal
Wkly Rep 2009;58(39):1100–1.
[28] Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccina-
tion of healthcare workers: a 5-year study. Infect Control Hosp Epidemiol
2010;31(9):881–8.
[29] Talbot TR. Improving rates of influenza vaccination among healthcare
workers: educate; motivate; mandate? Infect Control Hosp Epidemiol
2008;29(2):107–10.
[30] Polgreen PM, Septimus EJ, Parry MF, Beekmann SE, Cavanaugh JE, Srinivasan
A, et al. Relationship of influenza vaccination declination statements and
influenza vaccination rates for healthcare workers in 22 US hospitals. Infect
Control Hosp Epidemiol 2008;29(7):675–7.
[31] Palmore TN, Vandersluis JP, Morris J, Michelin A, Ruprecht LM, Schmitt
JM, et al. A successful mandatory influenza vaccination campaign using
an innovative electronic tracking system. Infect Control Hosp Epidemiol
2009;30(12):1137–42.
[32] SteelFisher GK, Blendon RJ, Bekheit MM, Lubell K. The public’s response to the
2009 H1N1 influenza pandemic. N Engl J Med 2010;362(22):pe65.
[33] Maurer J, Uscher-Pines L, Harris KM. Perceived seriousness of seasonal
and A(H1N1) influenzas, attitudes toward vaccination, and vaccine uptake
among U.S. adults: does the source of information matter? Prev Med
2010;51(2):185–7.
    • "The interventions with the largest observed increases (>25%) in vaccine uptake (Outcome 1) were those that (not in order of importance ): (1) directly targeted unvaccinated or under-vaccinated populations [13]; (2) aimed to increase vaccination knowledge and awareness [20]; (3) improved convenience and access to vaccination [116]; (4) targeted specific populations (e.g. HCW) [9]; (5) mandated vaccinations or sanction against non-vaccination [46]; and (6) engaged religious or other influential leaders to promote vaccination [177] . The greatest increases (>20%) in knowledge , awareness or attitudes (Outcome 2) were observed with education initiatives, particularly those embedding new knowledge into routine processes (e.g. "
    [Show abstract] [Hide abstract] ABSTRACT: The purpose of this systematic review is to identify, describe and assess the potential effectiveness of strategies to respond to issues of vaccine hesitancy that have been implemented and evaluated across diverse global contexts. A systematic review of peer reviewed (January 2007-October 2013) and grey literature (up to October 2013) was conducted using a broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy concerning vaccines. This search strategy was applied and adapted across several databases and organizational websites. Descriptive analyses were undertaken for 166 (peer reviewed) and 15 (grey literature) evaluation studies. In addition, the quality of evidence relating to a series of PICO (population, intervention, comparison/control, outcomes) questions defined by the SAGE Working Group on Vaccine Hesitancy (WG) was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria; data were analyzed using Review Manager. Across the literature, few strategies to address vaccine hesitancy were found to have been evaluated for impact on either vaccination uptake and/or changes in knowledge, awareness or attitude (only 14% of peer reviewed and 25% of grey literature). The majority of evaluation studies were based in the Americas and primarily focused on influenza, human papillomavirus (HPV) and childhood vaccines. In low- and middle-income regions, the focus was on diphtheria, tetanus and pertussis, and polio. Across all regions, most interventions were multi-component and the majority of strategies focused on raising knowledge and awareness. Thirteen relevant studies were used for the GRADE assessment that indicated evidence of moderate quality for the use of social mobilization, mass media, communication tool-based training for health-care workers, non-financial incentives and reminder/recall-based interventions. Overall, our results showed that multicomponent and dialogue-based interventions were most effective. However, given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, identified strategies should be carefully tailored according to the target population, their reasons for hesitancy, and the specific context. Copyright © 2015. Published by Elsevier Ltd.
    Full-text · Article · Apr 2015
    • "Despite these limitations, our study provides evidence that modest incentives such as one-hour paid time off will be unlikely to promote influenza vaccination rates within medical facilities. More potent interventions that include mandatory vaccination [15] combined with penalties for noncompliance [16] will likely provide the only means to achieve near-universal influenza vaccination among HCWs. "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives. The national influenza vaccination rate among healthcare workers (HCWs) remains low despite clear benefits to patients, coworkers, and families. We sought to evaluate formally the effect of a one-hour time off incentive on attitudes towards influenza vaccination during the 2011-2012 influenza season. Methods. All HCWs at the Philadelphia Veterans Affairs (VA) Medical Center were invited to complete an anonymous web-based survey. We described respondents' characteristics and attitudes toward influenza vaccination and determined the relationship of specific attitudes with respondents' acceptance of influenza vaccination, using a 5-point Likert scale. Results. We analyzed survey responses from 154 HCWs employed at the Philadelphia VA Medical Center, with a response rate of 8%. Among 121 respondents who reported receiving influenza vaccination, 34 (28%, 95% CI 20-37%) reported agreement with the statement that the time off incentive made a difference in their decision to accept influenza vaccination. Conclusions. Our study provides evidence that modest incentives such as one-hour paid time off will be unlikely to promote influenza vaccination rates within medical facilities. More potent interventions that include mandatory vaccination combined with penalties for noncompliance will likely provide the only means to achieve near-universal influenza vaccination among HCWs.
    Full-text · Article · Jun 2013
    • "Also, sharing stories from the Shot by Shot website, perhaps one story per month during the school year, could help focus attention on a particular vaccine every month. Employer vaccine mandates have been shown to increase vaccination uptake among employees in the health care setting (Harris et al., 2011). When considering that almost half of the subjects in this study supported vaccine mandates for adults, the school nurse might want to lead the cause of school personnel vaccination mandates with the school districts. "
    [Show abstract] [Hide abstract] ABSTRACT: As key members of the school environment, it is important for school employees to be vaccinated. Employees are in direct contact with children in close quarters for long periods of time and such an environment can easily serve as an outbreak center for vaccine-preventable communicable diseases such as measles. Despite the fact that most school employees believe vaccines are safe and effective and many school employees report they are up-to-date with their vaccines, a closer examination reveals discrepancy between belief and behavior. This research study evaluates the vaccination status, awareness, and perceptions of school employees located in a large rural school district in Utah. As a vaccine advocate, the school nurse can be influential in providing adult vaccination education for school employees, thus increasing awareness of the importance of adult vaccines and knowing one's vaccination status. Additionally, school nurses might need to meet with school district policy makers to promote vaccine mandates for school employees and to assist in the creation of containment plans in the event of a measles outbreak at school.
    Full-text · Article · May 2013
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