Factorial design for improving influenza vaccination among employees of a large health system.

OBJECTIVE: As healthcare personnel (HCP) influenza vaccination becomes a quality indicator for healthcare facilities, effective interventions are needed. This study was designed to test a factorial design to improve HCP vaccination rates. DESIGN: A before-after trial with education, publicity, and free and easily accessible influenza vaccines used a factorial design to determine the effect of mobile vaccination carts and incentives on vaccination rates of HCP, who were divided into groups on the basis of their level of patient contact (ie, business and/or administrative role, indirect patient contact, and direct patient contact). SETTING: Eleven acute care facilities in a large health system. PARTICIPANTS: More than 26,000 nonphysician employees. RESULTS: Influenza vaccination rates increased significantly in most facilities and increased system-wide from 32.4% to 39.6% (P<.001). In the baseline year, business unit employee vaccination rates were significantly higher than among HCP with patient contact; rates did not differ significantly across groups in the intervention year. In logistic regression that accounted for demographic characteristics, intervention year, and other factors, the use of incentives and/or mobile carts that provided access to vaccine at the work unit significantly increased the likelihood of vaccination among HCP with direct and indirect patient contact, compared with control sites. CONCLUSIONS: Interventions to improve vaccination rates are differentially effective among HCP with varying levels of patient contact. Mobile carts appear to remove access barriers, whereas incentives may motivate HCP to be vaccinated. Education and publicity may be sufficient for workers in business or administrative positions. Interventions tailored by worker type are likely to be most successful for improving HCP vaccination rates.

HPV vaccine and its recommendations, 2007.

Quadrivalent human papillomavirus vaccine against the viral types most likely to cause cervical cancer (types 16 and 18) and genital warts (types 6 and 11) has been licensed in the United States. The vaccine is 95% to 100% efficacious against cervical intraepithelial neoplasia and adenocarcinoma in situ and 99% efficacious against genital warts caused by serotypes in the vaccine. Local pain injection site pain and swelling are the main adverse reactions. Routine vaccination of females at 11 to 12 years of age is recommended. Catch-up vaccination is recommended for females age 13 to 26 years who have not yet been vaccinated, and vaccination of girls 9 and 10 years of age is permitted at the discretion of the physician.

Recent changes in influenza vaccination recommendations, 2007.

Influenza disease continues to cause thousands of deaths in the United States. Due to the burden of influenza hospitalizations among children, inactivated influenza vaccine is now routinely recommended for children age 6 to 59 months. Live attenuated influenza vaccine is available for healthy persons 5 to 49 years of age. Other recent developments include routine vaccination of pregnant women with inactivated vaccine and an emphasis on the vaccination of health care workers.

Routine vaccines across the life span, 2007.

Routine vaccines are listed on the Recommended Childhood and Adolescent Immunization Schedule and the Recommended Adult Immunization Schedule published by the Centers for Disease Control and Prevention and reviewed and updated by the Advisory Committee on Immunization Practices. For these vaccines, we discuss the disease burden, rationale for vaccination, efficacy, adverse reactions, and recommendations. Some new vaccines are discussed here (Tdap and zoster), whereas others (rotavirus and human papillomavirus) are discussed elsewhere in the supplement.

Vaccines for persons at high risk, 2007.

Morbidity and mortality due to vaccine-preventable diseases are high among persons with underlying medical conditions. Thus, inactivated influenza and pneumococcal polysaccharide vaccines are recommended for individuals with cardiac disease, diabetes mellitus, chronic obstructive pulmonary disease, immunosuppression, and other chronic illnesses. Inactivated influenza vaccine is recommended for pregnant women and for persons with asthma and neuromuscular disease. Palivizumab, a respiratory syncytial virus immunoglobulin preparation, is recommended for certain infants with prematurity and chronic lung disease. Health care workers are at high risk for acquiring and transmitting hepatitis B, pertussis, measles, varicella, and influenza; hence, vaccination against these diseases is recommended. A signed declination is recommended for health care workers who refuse influenza vaccination.

Vaccine schedules and procedures, 2007.

This article reviews the 2007 recommended childhood and adolescent immunization schedules; the catch-up immunization schedules for children and adolescents; the 2006-2007 recommended adult immunization schedule; recommended and minimum ages and intervals between vaccine doses; contraindications for immunization; and general guidelines on immunization procedures. With the exception of some formulations of influenza vaccines, all recommended childhood vaccines are thimerosal-free. Since 2005, changes in vaccine schedules affect the following vaccinations: hepatitis A, rotavirus, human papillomavirus, varicella, meningococcal, adult tetanus and diphtheria toxoids and acellular pertussis, and influenza. Minimal intervals between vaccines and vaccine precautions, contraindications, administration, and storage are reviewed. Sources of up-to-date vaccine information are presented.

Addressing immunization barriers, benefits, and risks.

Vaccines have been highly effective in eliminating or significantly decreasing the occurrence of many once-common diseases. Barriers to immunization are a significant factor in the rising incidence rates of some vaccine-preventable diseases. Cost, reduced accessibility to immunizations, increasingly complex childhood and adolescent/adult immunization schedules, and increasing focus on the potential adverse effects of vaccines all contribute to difficulty in meeting the 2010 immunization goals. Physicians must not only be knowledgeable about vaccines but they must incorporate systems in their offices to record, remind, and recall patients for vaccinations. They must also clearly communicate vaccine benefits and risks while understanding those factors that affect an individual's acceptance and perception of those benefits and risks.

Rationing of influenza vaccine during a pandemic: ethical analyses.

Rationing of scarce vaccine supplies will likely be required when the next pandemic occurs, raising the questions about how to ration and upon what principles. Because influenza pandemics have differing mortality patterns, such as the 1918 pandemic's "W" shaped curve that effected healthy young adults, the particular pattern should inform rationing. Competing ethical principles for vaccine rationing are utilitarianism and egalitarianism. Vaccine manufacturers and essential healthcare workers can be justified with either principle. Utilitarian principles of choosing based on social worth or those in whom vaccination is most likely to medically succeed raise substantial justice issues. Egalitarian principles of medical neediness and random chance avoid justice concerns and are proposed. A framework that uses multiple principles to address influenza vaccine rationing in light of a shortage is recommended.

Tailored interventions to introduce influenza vaccination among 6- to 23-month-old children at inner-city health centers.

BACKGROUND: Because of high rates of hospitalization for influenza infections among very young children (< 2 years), the Advisory Committee on Immunization Practices initiated a new policy in 2002 that encouraged vaccination of healthy children aged 6 to 23 months against influenza. OBJECTIVE: To evaluate the effectiveness of implementing tailored interventions to introduce influenza vaccination of children 6 to 23 months of age in inner-city practices. STUDY DESIGN: A before-after trial with historical and concurrent controls was conducted in 6 health centers in low-income urban locations. METHODS: Intervention sites were selected, and interventions (directed at 1534 patients who were 6 to 23 months old) were implemented from a menu of strategies. Vaccination rates were measured from medical record reviews. Focus groups of nursing staffs provided evaluative information on strategies. RESULTS: Influenza vaccination rates improved significantly at the intervention health centers compared with the control center. Preintervention (2001-2002) rates ranged from 0% to 7.6%, and intervention (2002-2003) rates ranged from 15.2% to 49.2% (P < .001). The number of interventions ranged from 6 to 11. Sites that used more interventions (odds ratio, 1.24; 95% confidence interval, 1.15-1.34) and had staff support of the vaccination effort (odds ratio, 1.91; 95% confidence interval, 1.40-2.60) had higher vaccination rates. CONCLUSIONS: Tailored interventions resulted in successful introduction of influenza vaccination of 6- to 23-month-old children in inner-city health centers. More strategies and enthusiastic staff support may result in higher vaccination rates.

What predicts influenza vaccination status in older Americans over several years?

OBJECTIVES: To examine the correlates of repeat influenza vaccination and determine whether there are age-group (50-64, > or =65) differences in decision-making behavior. DESIGN: Longitudinal survey study. SETTING: Two community health centers in Pittsburgh, Pennsylvania. PARTICIPANTS: Two hundred fifty-three patients aged 50 and older in 2001 who visited one of the health centers and completed telephone surveys in 2002 and 2003 after the respective influenza seasons. MEASUREMENTS: Influenza vaccination status, demographic characteristics, and decision-making behavior were self-reported. Vaccination status was identified for three seasons: 2000-2001, 2001-2002, and 2002-2003. A three-level outcome was defined as unvaccinated all 3 years, vaccinated one to two times over 3 years, and vaccinated all 3 years. Factor analysis identified three decision-making behaviors. RESULTS: Predictors of being vaccinated across 3 years included being older, the belief that social forces influence vaccination behavior, and disagreement with the view that vaccine is detrimental. CONCLUSION: National educational efforts should be intensified to dispel the myths about alleged adverse events, including contracting influenza from inactivated influenza vaccine. Physicians should continue to share their personal experiences of treating patients with influenza, including the incidence of hospitalization and death.

If pneumonia is the "old man's friend", should it be prevented by vaccination? An ethical analysis.

Because pneumococcal disease is a major problem among the elderly, pneumococcal polysaccharide vaccination is widely promoted. However, Sir William Osler called pneumonia the friend of the aged, leading to an ethical discussion. Mortality from pneumonia is higher with increasing degrees of underlying illness, outweighing the age effect. Although some symptoms are less common in the elderly, other symptoms are not and the duration may be longer. Problematic criteria for limiting pneumococcal polysaccharide vaccination include age, social value, and quality of life. Recommended criteria for limiting vaccination include autonomous patient refusal, imminent death, and lack of medical benefit, as would be seen in hospice cases.

The 2002 United States varicella vaccine shortage and physician recommendations for vaccination.

BACKGROUND: The US experienced a shortage of varicella vaccine in 2002, leading to the concerns about its impact. METHODS: 204 Minnesota and Pennsylvania physicians, most (164) of whom were interviewed in 1999 on the topic of varicella vaccine, responded to a 2003 survey. RESULTS: Although 67% were aware of the 2002 varicella vaccine shortage, 24% experienced it and only 45% were aware of the 2002 temporary change in national vaccination recommendations. In response, more vaccinated until the supply was exhausted (59%) than postponed vaccination as recommended (41%). Most (91%) reported that the shortage did not change their likelihood of recommending vaccine. From 1999 to 2003, the percentage of physicians highly likely to recommend vaccination increased from 73% to 82% for children 12-18 months old (P < 0.01). In 2003, more physicians believed that it was likely for secondary skin infections to occur following varicella disease and for parents to request vaccination than in 1999 (P < 0.01). Almost all (93%) physicians in both years believed that serious side effects were unlikely. CONCLUSIONS: Over half of physicians were unaware of the change in vaccine recommendations due to the shortage and many did not follow that change, suggesting the need for a different strategy.

Missed opportunities to vaccinate older adults in primary care.

OBJECTIVE: During the 2000 to 2001 influenza season, distribution of influenza vaccine was delayed, and national self-reported vaccination rates declined. The purposes of this study were to characterize missed opportunities for adult vaccinations and assess the impact of the vaccine delay on missed opportunities for influenza vaccination as recorded in medical records. METHODS: In a cross-sectional analysis, medical record data from 217 adult patients aged > or =65 years in primary care practices that received influenza vaccine supplies late in 2000 were used to assess rates and missed opportunities to vaccinate. Missed opportunities were defined as visits in which there was no record that vaccine had been given, discussed, or refused by the patient. RESULTS: During the mean study period of 37.1 +/- 5.7 months, patients averaged 12.1 +/- 5.9 visits to their primary care physician's office. Medical records indicated that 75% of patients had received pneumococcal polysaccharide vaccine (PPV) and 30% had received tetanus toxoid from 1991 to 2001; 81% had received at least one influenza vaccine in the previous 4 seasons. During the 2000 to 2001 influenza season, influenza vaccination rates declined significantly to 41% from 57% in 1999 to 2000. Overall missed opportunities to vaccinate during the study period averaged 3.4 +/- 3.0 for influenza vaccine, 10.7 +/- 7.3 for pneumococcal vaccine, and 10.8 +/- 5.9 for tetanus toxoid. During the delay season, the number of visits increased, but missed opportunities to vaccinate also increased significantly, even after vaccine supplies had been received. CONCLUSIONS: Missed opportunities to vaccinate occur frequently and vaccine shortages create additional challenges to adult vaccination. Missed opportunities may be minimized and maintenance of accurate adult immunization records may be achieved by assessing and recording vaccination status at each visit, regardless of vaccine availability. By so doing, providers can easily convey the message to their patients that immunizations are an important part of their care.

Recent changes in influenza epidemiology and vaccination recommendations.

Influenza disease continues to cause thousands of deaths in the United States. Due to the burden of influenza hospitalizations among children, inactivated influenza vaccine is now routinely recommended for children age 6-23 months. A live, attenuated influenza vaccine was licensed in 2003 for healthy persons age 5-49 years.

Vaccines for persons at high risk due to medical conditions, occupation, environment, or lifestyle, 2005.

The rates of morbidity and mortality due to influenza and pneumococcal diseases are high among persons with underlying medical conditions; thus, influenza and pneumococcal polysaccharide vaccines are recommended for those with cardiac disease, diabetes mellitus, chronic obstructive pulmonary disease, and other chronic illnesses. For the same reasons, influenza vaccine is recommended for pregnant women and for persons with asthma. Health care workers are at high risk for acquiring and transmitting hepatitis B, measles, varicella, and influenza; hence, vaccination against these diseases is recommended.

Vaccine schedules and procedures.

This article presents the 2005 Recommended Childhood and Adolescent Immunization Schedule; the catch-up schedule; the 2004-2005 Recommended Adult Immunization Schedule, which will stay in effect for 2005; contraindications for immunization; and general guidelines on immunization procedures. Recent changes for children include institution of thimerosal-free hepatitis B vaccination either before hospital discharge or as soon after birth as possible and the recommendation to give inactivated influenza vaccine to all children who will be between the ages of 6 and 23 months during the influenza season. Minimal intervals between vaccines and vaccine precautions, contraindications, administration, and storage are reviewed. Sources of vaccine information are presented and discussed.

Immunization barriers and solutions.

Too many children and adults in the United States develop vaccine-preventable diseases each year. Patients, parents, and providers face a variety of barriers that cause us to fall short of our immunization goals. This article discusses ways in which providers can surmount those barriers and improve immunization rates.

Routine vaccines across the life span, 2005.

Routine vaccines include those listed on the Recommended Childhood and Adolescent Immunization Schedule and the Recommended Adult Immunization Schedule. The disease burden, rationale for vaccination, efficacy, adverse reactions, and recommendations are discussed in relation to each vaccine. Pictures of vaccine-preventable diseases are included.