COVID-19 vaccine coverage among immigrants and refugees in Alberta: A population-based cross-sectional study

Background

Studies have shown that immigrants have lower vaccination rates than the Canadian-born population. We sought to assess COVID-19 vaccine coverage and factors associated with uptake among foreign-born immigrants relative to the non-immigrant population in Alberta, Canada.

Methods

In this cross-sectional study, we analysed population-based linked administrative health data from Alberta to examine vaccine coverage for 3 931 698 Albertans, of which 731 217 were immigrants. We calculated COVID-19 vaccination coverage as the proportion of eligible Albertans with a record of receiving at least one dose of a COVID-19 vaccine as of November 29, 2021. We used multivariable logistic regression to examine the association of vaccine coverage with migration status (immigrants: four categories based on time since migration and non-immigrants) adjusting for socio-demographic variables.

Results

Overall, COVID-19 vaccination coverage was 78.2% (95% confidence interval (CI) = 78.1%-78.3%) among immigrants and 76.0% (95% CI = 75.9%-76.0%) among non-immigrants. Coverage among immigrants differed by continent of origin, with North America, Oceania, and Europe having the lowest coverage. Although vaccine coverage was relatively uniform across neighbourhood income quintiles for immigrants, immigrants living in rural areas had lower vaccine coverage compared to non-immigrants living in rural areas. Multivariable logistic regression analysis showed a significant interaction between age category and migration status. While immigrants below 50 years of age generally had significantly higher vaccine coverage compared to non-immigrants, there was some variation based on time since migration. Immigrants above 50 years of age showed significantly lower coverage compared to non-immigrants of the same age.

Conclusions

Public health interventions should focus on older immigrants, immigrants living in rural areas, and immigrants from specific continental backgrounds in order to improve COVID-19 vaccination coverage.

Risk perceptions regarding inclusion of seasonal influenza vaccinations in the school immunization program in Israel: Arab vs. Jewish mothers

Background

The issue of whether to include seasonal influenza vaccinations in school-located vaccination programs (SLIV) has been examined in many countries, mainly in the context of economic effectiveness and morbidity prevention. Yet not enough studies have examined the impact of parental risk perceptions, health literacy and SLIV on parental vaccination uptake.

Objectives

The most recent statistics in Israel point to a higher rate of seasonal influenza vaccination among Arab children (aged 7–9 years) than among Jewish children in the same age group. The present study attempts to explain this high vaccination uptake among mothers from Arab society by comparing their risk perceptions regarding seasonal influenza vaccination and disease to those of Jewish mothers. The study further examines the impact of SLIV on parental risk perceptions and influenza vaccination uptake.

Methods

This cross-sectional study included mothers of children in the second and third grades faced with the decision of whether their children should receive the seasonal influenza vaccination at school. The study population included a stratified sample of Jewish mothers (n = 159) and Arab mothers from all the Arab population sub-groups: Muslim, Christian, Druse and Bedouin (n = 534).

Results

A comparison of the Arab and Jewish populations revealed a significant difference in vaccination rates; 61.7% among Arab mothers compared to 33.5% among Jewish mothers (χ²(1) = 39.15, P<0.0001). Moreover, significant differences emerged between the Arab and Jewish populations in health literacy and ability to seek information regarding the seasonal influenza vaccination (t (691) = -5.81, p < 0.0001). While no differences emerged in mothers’ perceptions regarding influenza as a disease (t (691) = 1.20, p = 0.2318), Arab mothers perceived the vaccination to be safer than Jewish mothers (t (691) = 2.74, p = 0.0063) and saw its inclusion in the school-located vaccination program as providing more legitimacy (Z = -6.6719, P < .0001).

Conclusion

This study showed that the factors influencing vaccination uptake among both the Arab and the Jewish populations include perceived influenza risk, perceived vaccination risk, inclusion in the school-located vaccination program and health literacy. Moreover, influenza vaccination uptake is higher among those who have positive attitudes toward vaccinations, low risk perceptions regarding the vaccine, and low health literacy that impedes their ability to seek information. The research also points to the need for education and tools to boost health literacy among minority groups so that mothers can make independent and informed decisions about whether or not to vaccinate their children.

Effectiveness of influenza vaccination in preventing hospitalisation due to influenza in children: a systematic review and meta-analysis

This systematic review assesses the literature for estimates of influenza vaccine effectiveness (IVE) against laboratory-confirmed influenza-associated hospitalisation in children. Studies of any design to 08 June 2020 were included if the outcome was hospitalisation, participants were 17 years old or less and influenza infection was laboratory-confirmed. A random-effects meta-analysis of 37 studies that used a test-negative design gave a pooled seasonal IVE against hospitalisation of 53.3% (47.2-58.8) for any influenza. IVE was higher against influenza A/H1N1pdm09 (68.7%, 56.9-77.2) and lowest against influenza A/H3N2 (35.8%, 23.4-46.3). Estimates by vaccine type ranged from 44.3% (30.1-55.7) for LAIV to 68.9% (53.6-79.2) for inactivated vaccines. IVE estimates were higher in seasons when the circulating influenza strains were antigenically matched to vaccine strains (59.3%, 48.3-68.0). Influenza vaccination gives moderate overall protection against influenza-associated hospitalisation in children supporting annual vaccination. IVE varies by influenza subtype and vaccine type.

A review of vaccine effects on women in light of the COVID-19 pandemic

The pandemic situation triggered by the spread of COVID-19 has caused great harm worldwide. More than six million people have been infected, and more than 360,000 of them have died. This is the worst catastrophe suffered by mankind in recent history. In the face of this severe disaster, people all over the world are frightened of the prospect of facing an outbreak or an annual recurrence. However, the development of a vaccine will help control the impact of COVID-19. Women in particular have been more seriously affected by the pandemic. Since the pressure and physical load they suffer are often greater than what men endure, women are more threatened by COVID-19. Though women have a poorer quality of life and work and face worse economic conditions, they also tend to have better physiological immunity than men, which can ease the effect of COVID-19. The early development of a vaccine against COVID-19 is an important issue that must take into consideration women's better immune response to the virus along with the technique of hormone regulation. Relevant research has been conducted on female-specific vaccines in the past, and women's issues were considered during those clinical trials to ensure that complications and antibody responses were positive and effective in women. National policies should also propose good strategies for women to be vaccinated. This could improve consciousness, give women a better vaccination experience, enhance their willingness to vaccinate, and protect them from COVID-19 infection.

Seasonal influenza vaccination in older people: A systematic review and meta-analysis of the determining factors

Background/Objectives

Despite influenza vaccination programs in various jurisdictions, seasonal influenza vaccine (SIV) uptake remains suboptimal among older people (≥65years old), an important subpopulation for influenza vaccination. We sought to summarize determinants of SIV uptake (any vaccine receipt) and vaccination adherence (receipt of vaccine in two or more seasons in sequence) among older people.

Methods

We searched for population-based studies conducted in community-dwelling older people (irrespective of their health status) from 2000–2019. Two reviewers independently selected publications for inclusion. One reviewer extracted data from the included studies; a second checked the extracted data for errors. Disagreements were resolved by discussion and consensus, or a third reviewer. We were interested in the determinants of SIV uptake and vaccination adherence. Where appropriate, we pooled adjusted results using the inverse variance, random-effects method and reported the odds ratios (OR) and their 95% confidence intervals (CI).

Results

Out of 11,570 citations screened, we included 34 cross-sectional studies. The following were associated with increased SIV uptake: being older (OR 1.52, 95%CI 1.38–1.67 [21 studies]), white (1.30, 1.14–1.49 [10 studies]), married (1.23, 1.17–1.28 [9 studies]), non-smoker (1.28, 1.11–1.47 [7 studies]), of a higher social class (1.20, 1.06–1.36 [2 studies]), having a higher education (1.12, 1.04–1.21 [14 studies]), having a higher household income (1.11, 1.05–1.18 [8 studies]), having a chronic illness (1.53, 1.44–1.63 [16 studies]), having poor self-assessed health (1.23, 1.02–1.40 [9 studies]), having a family doctor (2.94, 1.79–4.76 [2 studies]), and having health insurance (1.58, 1.13–2.21 [6 studies]). The influence of these factors varied across geographical regions. Being older (1.26, 1.11–1.44 [2 studies]) was also associated with increased vaccination adherence.

Conclusions

Several factors may determine SIV uptake and vaccination adherence among older people. More studies are needed to provide a stronger evidence base for planning more effective influenza vaccination programs.

Optimal Design of Population-Level Financial Incentives of Influenza Vaccination for the Elderly

OBJECTIVES

To identify how monetary incentives affect influenza vaccination uptake rate using a randomized control experiment and to subsequently design an optimal incentive program in Singapore, a high-income country with a market-based healthcare system.

METHODS

4000 people aged ≥65 were randomly assigned to 4 treatment groups (1000 each) and were offered a monetary incentive (in shopping vouchers) if they chose to participate. The baseline group was invited to complete a questionnaire with incentives of 10 Singapore dollars (SGD; where 1 SGD ≈ 0.73 USD), whereas the other three groups were invited to complete the questionnaire and be vaccinated against influenza at their own cost of around 32 SGD, in return for incentives of 10, 20, or 30 SGD.

RESULTS

Increasing the total incentive for vaccination and reporting from 10 to 20 SGD increased participation in vaccination from 4.5% to 7.5% (P < .001). Increasing the total incentive from 20 to 30 SGD increased the participation rate to 9.2%, but this was not statistically significantly different from a 20-SGD incentive. The group of nonworking elderly were more sensitive to changes in incentives than those who worked. In addition to working status, the effects of increasing incentives on influenza vaccination rates differed by ethnicity, socio-economic status, household size, and a measure of social resilience. There were no significant differential effects by age group, gender, or education, however. The cost of the program per completed vaccination under a 20-SGD incentive is 36.80 SGD, which was the lowest among the three intervention arms. For a hypothetical population-level financial incentive program to promote influenza vaccination among the elderly, accounting for transmission dynamics, an incentive between 10 and 20 SGD minimizes the cost per completed vaccination from both governmental and health system perspectives.

CONCLUSIONS

Appropriate monetary incentives can boost influenza vaccination rates. Increasing monetary incentives for vaccination from 10 to 20 SGD can improve the influenza vaccination uptake rate, but further increasing the monetary incentive to 30 SGD results in no additional gains. A partial incentive may therefore be considered to improve vaccination coverage in this high-risk group.

Serum Vitamin D and Immunogenicity of Influenza Vaccination in the Elderly

Vaccination is the most effective preventive measure that reduces the risk of influenza and post-influenza complications. It prevents influenza-related hospitalizations and deaths in 50-60% and about 80% of patients aged over 65, respectively. There is the clinical plausibility of the association between serum vitamin D (VIT D) content and viral respiratory infections. In this study, we addressed the issue of a vitamin D modulatory effect on the immune response to seasonal influenza vaccination in elderly persons. The study comprised 96 participants aged 60-75 during the 2016/17 epidemic season. After the determination of the baseline content of VIT D and anti-hemagglutinin antibodies (H1, H3, and HB), participants were vaccinated with a trivalent vaccine. The content of the anti-hemagglutinin antibodies was rechecked 4-5 weeks afterward, showing inappreciable alterations. The negative findings of this study make the influence of serum VIT D content on the immunogenicity of influenza vaccination highly unlikely in elderly persons.

Determinants of Seasonal Influenza Vaccine Uptake Among the Elderly in the United States: A Systematic Review and Meta-Analysis

Background: Despite the availability of a universal influenza vaccination program in the United States and Canada, seasonal influenza vaccine (SIV) uptake among the elderly remains suboptimal. Understanding the factors that determine SIV uptake in this important population subgroup is essential for designing effective interventions to improve seasonal influenza vaccination among the elderly. We evaluated the determinants of SIV uptake in the elderly in the United States and Canada. Methods: We systematically searched relevant bibliographic databases and websites from 2000 to 2017 for population-based clinical trials or observational studies conducted in community-based elderly individuals in the United States or Canada, irrespective of health status. Two reviewers independently screened the identified citations for eligibility using a two-stage sifting approach to review the title/abstract and full-text article. We gathered data on determinants of uptake (any vaccine receipt) and adherence (receipt of vaccine in more than one season) to seasonal influenza vaccination. Where possible, we pooled the data using inverse variance methods to minimize the variance of the weighted average. Results: Five cross-sectional studies on SIV uptake (none on adherence) from the United States met our eligibility criteria. Being older (pooled odds ratio [POR] = 1.44, 95% Confidence Interval [CI] = 1.11, 1.86); White (POR = 1.33, 95% CI = [1.10, 1.64]); and having higher income (POR = 1.06, 95% CI = [1.04, 1.09]); and health insurance (POR = 1.40, 95% CI = [1.25, 1.55]) were associated with increased SIV uptake. Conclusion: Older, ethnically White, higher income elderly individuals with access to health insurance coverage and a regular health care provider have higher SIV uptake in the United States. There was limited evidence for other socioeconomic and health-related determinants. Further studies are needed to provide an evidence base for planning more effective influenza vaccination programs in the United States.

Impact of influenza on outpatient visits and hospitalizations among pregnant women in Catalonia, Spain

OBJECTIVE

To estimate outpatient visits and hospitalization rates due to cardiopulmonary illness attributable to influenza from 2008-09 to 2012-13 in a large cohort of pregnant women from Catalonia, Spain.

METHODS

We estimated the event rates occurring during influenza epidemic, influenza non-epidemic and non-influenza seasons, and by pregnancy status (one year before pregnancy, first, second and third trimester). We fitted quasi-Poisson models in order to identify the variables associated to higher event rates.

RESULTS

During influenza epidemic seasons, pregnant women in their second trimester had the highest rates of outpatient visits (153 per 10,000 women-months). An increased risk of outpatient visits was associated to first or second trimester (adjusted rate ratio (aRR) = 1.17; 95% CI, 1.10-1.23 and aRR, 1.36; 95% CI, 1.28-1.43, respectively) and having any comorbidity (aRR = 1.28; 95% CI, 1.21-1.36). Women during third trimester had the highest rates of hospitalizations (1.60 per 10,000 women-months), and an increased risk of hospitalization was significantly associated to third trimester (aRR, 1.85; 95% CI, 1.01-3.39), having any comorbidity (aRR, 1.93; 95% CI, 1.10-3.41) and the pandemic influenza season (aRR, 2.90 (1.81; 95% CI, 1.81-4.64).

CONCLUSION

Our findings provide significant information regarding influenza burden of disease among pregnant women.

The potential economic value of influenza vaccination for healthcare workers in The Netherlands

Background

Despite the clinical evidence, influenza vaccination coverage of healthcare workers remains low. To assess the health economic value of implementing an influenza immunization program among healthcare workers (HCW) in University Medical Centers (UMCs) in the Netherlands, a cost‐benefit model was developed using a societal perspective.

Methods/Patients

The model was based on a trial performed among all UMCs in the Netherlands that included both hospital staff and patients admitted to the pediatrics and internal medicine departments. The model structure and parameters estimates were based on the trial and complemented with literature research, and the impact of uncertainty explored with sensitivity analyses.

Results

In a base‐case scenario without vaccine coverage, influenza‐related annual costs were estimated at € 410 815 for an average UMC with 8000 HCWs and an average occupancy during the influenza period of 6000 hospitalized patients. Of these costs, 82% attributed to the HCWs and 18% were patient‐related. With a vaccination coverage of 15.47%, the societal program’s savings were € 2861 which corresponds to a saving of € 270.53 per extended hospitalization. Univariate sensitivity analyses show that the results are most sensitive to changes in the model parameters vaccine effectiveness in reducing influenza‐like illness (ILI) and the vaccination‐related costs.

Conclusion

In addition to the decreased burden of patient morbidity among hospitalized patients, the effects of the hospital immunization program slightly outweigh the economic investments. These outcomes may support healthcare policymakers’ recommendations about the influenza vaccination program for healthcare workers.

The impact of vaccination and patient characteristics on influenza vaccination uptake of elderly people: A discrete choice experiment

OBJECTIVES

To improve information for patients and to facilitate a vaccination coverage that is in line with the EU and World Health Organization goals, we aimed to quantify how vaccination and patient characteristics impact on influenza vaccination uptake of elderly people.

METHODS

An online discrete choice experiment (DCE) was conducted among 1261 representatives of the Dutch general population aged 60 years or older. In the DCE, we used influenza vaccination scenarios based on five vaccination characteristics: effectiveness, risk of severe side effects, risk of mild side effects, protection duration, and absorption time. A heteroscedastic multinomial logit model was used, taking scale and preference heterogeneity (based on 19 patient characteristics) into account.

RESULTS

Vaccination and patient characteristics both contributed to explain influenza vaccination uptake. Assuming a base case respondent and a realistic vaccination scenario, the predicted uptake was 58%. One-way changes in vaccination characteristics and patient characteristics changed this uptake from 46% up to 61% and from 37% up to 95%, respectively. The strongest impact on vaccination uptake was whether the patient had been vaccinated last year, whether s/he had experienced vaccination side effects, and the patient's general attitude towards vaccination.

CONCLUSIONS

Although vaccination characteristics proved to influence influenza vaccination uptake, certain patient characteristics had an even higher impact on influenza vaccination uptake. Policy makers and general practitioners can use these insights to improve their communication plans and information regarding influenza vaccination for individuals aged 60 years or older. For instance, physicians should focus more on patients who had experienced side effects due to vaccination in the past, and policy makers should tailor the standard information folder to patients who had been vaccinated last year and to patient who had not.

Vaccines for preventing influenza in healthy children

BACKGROUND

The consequences of influenza in children and adults are mainly absenteeism from school and work. However, the risk of complications is greatest in children and people over 65 years of age. This is an update of a review published in 2011. Future updates of this review will be made only when new trials or vaccines become available. Observational data included in previous versions of the review have been retained for historical reasons but have not been updated because of their lack of influence on the review conclusions.

OBJECTIVES

To assess the effects (efficacy, effectiveness, and harm) of vaccines against influenza in healthy children.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 12), which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE (1966 to 31 December 2016), Embase (1974 to 31 December 2016), WHO International Clinical Trials Registry Platform (ICTRP; 1 July 2017), and ClinicalTrials.gov (1 July 2017).

SELECTION CRITERIA

Randomised controlled trials comparing influenza vaccines with placebo or no intervention in naturally occurring influenza in healthy children under 16 years. Previous versions of this review included 19 cohort and 11 case-control studies. We are no longer updating the searches for these study designs but have retained the observational studies for historical purposes.

DATA COLLECTION AND ANALYSIS

Review authors independently assessed risk of bias and extracted data. We used GRADE to rate the certainty of evidence for the key outcomes of influenza, influenza-like illness (ILI), complications (hospitalisation, ear infection), and adverse events. Due to variation in control group risks for influenza and ILI, absolute effects are reported as the median control group risk, and numbers needed to vaccinate (NNVs) are reported accordingly. For other outcomes aggregate control group risks are used.

MAIN RESULTS

We included 41 clinical trials (> 200,000 children). Most of the studies were conducted in children over the age of two and compared live attenuated or inactivated vaccines with placebo or no vaccine. Studies were conducted over single influenza seasons in the USA, Western Europe, Russia, and Bangladesh between 1984 and 2013. Restricting analyses to studies at low risk of bias showed that influenza and otitis media were the only outcomes where the impact of bias was negligible. Variability in study design and reporting impeded meta-analysis of harms outcomes.Live attenuated vaccinesCompared with placebo or do nothing, live attenuated influenza vaccines probably reduce the risk of influenza infection in children aged 3 to 16 years from 18% to 4% (risk ratio (RR) 0.22, 95% confidence interval (CI) 0.11 to 0.41; 7718 children; moderate-certainty evidence), and they may reduce ILI by a smaller degree, from 17% to 12% (RR 0.69, 95% CI 0.60 to 0.80; 124,606 children; low-certainty evidence). Seven children would need to be vaccinated to prevent one case of influenza, and 20 children would need to be vaccinated to prevent one child experiencing an ILI. Acute otitis media is probably similar following vaccine or placebo during seasonal influenza, but this result comes from a single study with particularly high rates of acute otitis media (RR 0.98, 95% CI 0.95 to 1.01; moderate-certainty evidence). There was insufficient information available to determine the effect of vaccines on school absenteeism due to very low-certainty evidence from one study. Vaccinating children may lead to fewer parents taking time off work, although the CI includes no effect (RR 0.69, 95% CI 0.46 to 1.03; low-certainty evidence). Data on the most serious consequences of influenza complications leading to hospitalisation were not available. Data from four studies measuring fever following vaccination varied considerably, from 0.16% to 15% in children who had live vaccines, while in the placebo groups the proportions ranged from 0.71% to 22% (very low-certainty evidence). Data on nausea were not reported.Inactivated vaccinesCompared with placebo or no vaccination, inactivated vaccines reduce the risk of influenza in children aged 2 to 16 years from 30% to 11% (RR 0.36, 95% CI 0.28 to 0.48; 1628 children; high-certainty evidence), and they probably reduce ILI from 28% to 20% (RR 0.72, 95% CI 0.65 to 0.79; 19,044 children; moderate-certainty evidence). Five children would need to be vaccinated to prevent one case of influenza, and 12 children would need to be vaccinated to avoid one case of ILI. The risk of otitis media is probably similar between vaccinated children and unvaccinated children (31% versus 27%), although the CI does not exclude a meaningful increase in otitis media following vaccination (RR 1.15, 95% CI 0.95 to 1.40; 884 participants; moderate-certainty evidence). There was insufficient information available to determine the effect of vaccines on school absenteeism due to very low-certainty evidence from one study. We identified no data on parental working time lost, hospitalisation, fever, or nausea.We found limited evidence on secondary cases, requirement for treatment of lower respiratory tract disease, and drug prescriptions. One brand of monovalent pandemic vaccine was associated with a sudden loss of muscle tone triggered by the experience of an intense emotion (cataplexy) and a sleep disorder (narcolepsy) in children. Evidence of serious harms (such as febrile fits) was sparse.

AUTHORS' CONCLUSIONS

In children aged between 3 and 16 years, live influenza vaccines probably reduce influenza (moderate-certainty evidence) and may reduce ILI (low-certainty evidence) over a single influenza season. In this population inactivated vaccines also reduce influenza (high-certainty evidence) and may reduce ILI (low-certainty evidence). For both vaccine types, the absolute reduction in influenza and ILI varied considerably across the study populations, making it difficult to predict how these findings translate to different settings. We found very few randomised controlled trials in children under two years of age. Adverse event data were not well described in the available studies. Standardised approaches to the definition, ascertainment, and reporting of adverse events are needed. Identification of all global cases of potential harms is beyond the scope of this review.

How close are countries of the WHO European Region to achieving the goal of vaccinating 75% of key risk groups against influenza? Results from national surveys on seasonal influenza vaccination programmes, 2008/2009 to 2014/2015

Background

Influenza vaccination is recommended especially for persons at risk of complications. In 2003, the World Health Assembly urged Member States (MS) to increase vaccination coverage to 75% among older persons by 2010.

Objective

To assess progress towards the 2010 vaccination goal and describe seasonal influenza vaccination recommendations in the World Health Organization (WHO) European Region.

Methods

Data on seasonal influenza vaccine recommendations, dose distribution, and target group coverage were obtained from two sources: European Union and European Economic Area MS data were extracted from influenza vaccination surveys covering seven seasons (2008/2009–2014/2015) published by the Vaccine European New Integrated Collaboration Effort and European Centre for Disease Prevention and Control. For the remaining WHO European MS, a separate survey on policies and uptake for all seasons (2008/2009–2014/2015) was distributed to national immunization programmes in 2015.

Results

Data was available from 49 of 53 MS. All but two had a national influenza vaccination policy. High-income countries distributed considerably higher number of vaccines per capita (median; 139.2 per 1000 population) compared to lower-middle-income countries (median; 6.1 per 1000 population). Most countries recommended vaccination for older persons, individuals with chronic disease, healthcare workers, and pregnant women. Children were included in < 50% of national policies. Only one country reached 75% coverage in older persons (2014/2015), while a number of countries reported declining vaccination uptake. Coverage of target groups was overall low, but with large variations between countries. Vaccination coverage was not monitored for several groups.

Conclusions

Despite policy recommendations, influenza vaccination uptake remains suboptimal. Low levels of vaccination is not only a missed opportunity for preventing influenza in vulnerable groups, but could negatively affect pandemic preparedness. Improved understanding of barriers to influenza vaccination is needed to increase uptake and reverse negative trends. Furthermore, implementation of vaccination coverage monitoring is critical for assessing performance and impact of the programmes.

Behavioural consequences of vaccination recommendations: An experimental analysis

Annual vaccination is the most effective way to prevent seasonal influenza. However, globally, the recommendations vary from country to country, ranging from universal recommendations, risk-group-specific recommendations, to no recommendation at all. Due to high diversity both in recommendation practice and country-specific preconditions, it is difficult to determine the effect of different recommendations on vaccine uptake. This incentivised laboratory experiment (N = 288) tests the behavioural consequences of different recommendations in a repeated interactive vaccination game. The participants are part of heterogeneous groups, comprised of low- and high-risk type of players. They receive either a universal, risk-group-specific or no recommendation prior to their vaccination decisions. Results show that individuals are sensitive to the recommendations. In detail, a risk-group-specific recommendation increases vaccine uptake of high-risk types. However, at the same time, it decreases vaccine uptake of low-risk types. The results imply that when the proportion of low-risk types in a population is considerably larger than the high-risk group, a risk-group-specific (vs. universal) recommendation comes at the cost of decreased social benefit of vaccination due to the overall lower vaccine uptake. Policy decision-making should therefore complement epidemiological considerations with potential positive and negative behavioural consequences of vaccination recommendations.

Focusing on the implementation of 21st century vaccines for adults

Adult immunization is a priority for public health, particularly in countries where an aging population has become increasingly more numerous. Protection against diseases which typically affect adults (like flu, pneumococcal diseases and Herpes zoster), the shift of age of infections which originally affected children (like measles), the decreasing protection with time for infections which need periodical booster doses of vaccines (Tdap), the availability of vaccines which can also impact on adult health (HPV) are only some examples of the importance of implementing targeted vaccination strategies. The possibility to reach high coverage with immunizations that can guarantee a fundamental improvement of health for adults and the elderly can only be achieved through a coordinated effort where all stakeholders, under the coordination of public health, contribute to issue recommendations; create a functioning database for vaccine coverage registration; promote formative courses for healthcare workers and continuous information for the public; increase vaccines uptake among healthcare workers, who need to give the first testimony on the relevance of immunization.

A population-based analysis of predictors of influenza vaccination uptake in pregnant women: The effect of gestational and calendar time

Pregnant women are vaccinated against influenza less frequently than other high-risk groups. To design effective vaccination strategies, we must understand how decisions regarding vaccination may vary by trimester and over vaccination campaigns. We used a Cox model indexed by calendar time to estimate the effect of gestational trimester and other factors on vaccination uptake in a large cohort of pregnant women in Catalonia (Spain) during 2008-09 to 2012-13 influenza vaccination campaigns. We analyzed 247,316 pregnancies. Vaccination coverage was 3.7%, 5.2%, 4.8%, 5.6% and 4.6% from 2008-09 to 2012-13 seasonal vaccination campaigns and 8.3% for the 2009 pandemic vaccination campaign. Pregnant women previously vaccinated had higher uptake than women not previously vaccinated and the hazard ratios (HRs) comparing these 2 groups decreased from 10, the first day of seasonal campaigns, to 1.3 the last day. During the pandemic campaign, HRs decreased over the course of the campaign from 8.6 to 1.9. Women in second and third trimester had higher uptake than women in first trimester, with HR=2.8 and 2.3, respectively, at the start of seasonal campaigns. Influenza vaccination coverage among this cohort of pregnant women was alarmingly low. Our analysis reveals that gestational and calendar time have distinct and interacting effects on vaccination uptake; women in their second trimester and third trimester and previously vaccinated were more prone to be vaccinated, but this effect wanes as the influenza season progresses.

Stepwise intervention including 1-on-1 counseling is highly effective in increasing influenza vaccination among health care workers

BACKGROUND

The influenza vaccination rate among health care workers (HCWs) remains suboptimal. We attempted to increase vaccine uptake in HCWs by nonmandatory measures, including 1-on-1 counseling.

METHODS

In 2015 we used a stepwise approach including (1) text messaging on the last day of the vaccination period, (2) extending the vaccination period by 3 days, (3) education for the low uptake group, and (4) 1-on-1 counseling for unvaccinated HCWs after the 3 interventions.

RESULTS

There were 1,433 HCWs included. By the end of the initial 3 days, the uptake rate was 80.0% (1,146/1,433). During an extension for a further 3 days, 33 additional HCWs received the vaccine. One month after starting the vaccination, 90.1% (1,291/1,433) of the HCWs were vaccinated, but this included only 76.1% (210/276) of the doctors (lowest among HCWs). After 3 educational presentations targeted at the unvaccinated doctors, no additional individuals were vaccinated in the following 2 weeks. After 1-on-1 counseling for unvaccinated HCWs, the overall vaccination rate increased to 94.7% (1,357/1,433) in 2015, higher than in the previous year (82.5%, P < .001). Of the unvaccinated doctors, 63.2% (43/68) were vaccinated, therefore achieving 92.4% (255/276) compliance, higher than the 56.5% in the previous year (152/269, P < .001).

CONCLUSIONS

Stepwise intervention including 1-on-1 counseling is effective in increasing influenza vaccination rates among HCWs.

Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia

BACKGROUND

Influenza vaccination of healthcare workers (HCWs) is essential for patient safety, their own safety, and hospital operation. However, despite its strong recommendation, studies indicates a low rate of vaccine uptake.

AIM

To assess rates of, and factors affecting, influenza vaccine uptake among HCWs.

METHODS

A cross-sectional survey was carried out during October 1^st to 16^th, 2015, among HCWs in King Abdullah Medical City in Makkah, Saudi Arabia. A self-administered, anonymous questionnaire was distributed to HCWs; this included questions on demographic characteristics, vaccine uptake, and knowledge, beliefs, attitude, and concern about influenza vaccine.

FINDINGS

Out of 500 HCWs approached, 447 returned valid self-reported questionnaires with response rate 89.4%. Overall, 88.3% of the participants reported receiving vaccination during the 2014/15 season, higher than during the 2013/14 (61.2%) and 2012/13 (54.5%) seasons. Self-protection (81.5%) was the main reason for vaccination, whereas 73.4% of HCWs reported vaccination to protect patients. The main reasons for vaccination avoidance were misconception that the vaccine causes influenza (38.5%) and concern about vaccine efficacy (32.7%). Logistic regression analysis revealed that the following were independently associated with vaccine receipt among HCWs: awareness of vaccine guidelines; intention to receive the vaccine next season; nurses and other HCWs compared to physicians; longer practice; and age >40 years.

CONCLUSION

A good uptake of influenza vaccine was achieved during the 2014/15 season following adoption of mandatory vaccination policy. Awareness programmes are needed to correct HCWs' misconceptions about the vaccine. Efforts need to focus especially on physicians, younger staff and new recruits.

The Clinical Impact and Cost Effectiveness of Quadrivalent Versus Trivalent Influenza Vaccination in Finland

BACKGROUND

Trivalent influenza vaccines encompass one influenza B lineage; however, predictions have been unreliable on which of two antigenically distinct circulating lineages will dominate. Quadrivalent seasonal influenza vaccines contain strains from both lineages. This analysis assesses the cost effectiveness of switching from trivalent inactivated influenza vaccination (TIV) in Finland to quadrivalent vaccination, using inactivated (QIV) or live-attenuated (Q-LAIV) vaccines.

METHODS

A transmission model simulated the dynamics of influenza infection while accounting for indirect (herd) protection. Prior distributions for key transmission parameters were repeatedly sampled and simulations that fitted the available information on influenza in Finland were recorded. The resulting posterior parameter distributions were used in a probabilistic sensitivity analysis in which economic parameters were sampled, simultaneously encompassing uncertainty in the transmission and economic parameters. The cost effectiveness of a range of trivalent and quadrivalent vaccine policies over a 20-year time horizon was assessed from both a societal and payer perspective in 2014 Euros.

RESULTS

The simulated temporal incidence pattern of symptomatic infections corresponded well with case surveillance data. A switch from the current TIV to Q-LAIV in children (2 to <18 years) and to QIV in other ages was estimated to annually avert approximately 76,100 symptomatic infections (95 % range 36,700-146,700), 11,500 primary care consultations (6100-20,000), 540 hospitalisations (240-1180), and 72 deaths (32-160), and was cost-saving relative to TIV (€374 million averted [€161-€752], in 2014 Euros, discounted at 3 %). This scenario had the highest probability of being the most cost-effective scenario considered.

CONCLUSIONS

This analysis demonstrates that quadrivalent vaccination is expected to be highly cost effective, reducing the burden of influenza-related disease.

Seasonal influenza vaccine policy, use and effectiveness in the tropics and subtropics - a systematic literature review

AIM

The evidence needed for tropical countries to take informed decisions on influenza vaccination is scarce. This article reviews policy, availability, use and effectiveness of seasonal influenza vaccine in tropical and subtropical countries.

METHOD

Global health databases were searched in three thematic areas - policy, availability and protective benefits in the context of human seasonal influenza vaccine in the tropics and subtropics. We excluded studies on monovalent pandemic influenza vaccine, vaccine safety, immunogenicity and uptake, and disease burden.

RESULTS

Seventy-four countries in the tropics and subtropics representing 60% of the world's population did not have a national vaccination policy against seasonal influenza. Thirty-eight countries used the Northern Hemisphere and 21 countries the Southern Hemisphere formulation. Forty-six countries targeted children and 57 targeted the elderly; though, the age cut-offs varied. Influenza vaccine supply increased twofold in recent years. However, coverage remained lower than five per 1000 population. Vaccine protection against laboratory-confirmed influenza in the tropics ranged from 0% to 42% in the elderly, 20-77% in children and 50-59% in healthy adults. Vaccinating pregnant women against seasonal influenza prevented laboratory-confirmed influenza in both mothers (50%) and their infants <6 months (49-63%).

CONCLUSION

Guidelines on vaccine composition, priority risk groups and vaccine availability varied widely. The evidence on vaccine protection was scarce. Countries in the tropics and subtropics need to strengthen and expand their evidence-base required for making informed decisions on influenza vaccine introduction and expansion, and how much benefit to expect.

Influenza vaccination prevalence and demographic factors of patients and GPs in primary care in Austria and Croatia: a cross-sectional comparative study in the framework of the APRES project

BACKGROUND

The aim of this study was to compare influenza vaccination coverage rates in Austria and Croatia, countries with missing data in the Eurosurveillance and European Centre for Disease Prevention and Control reports. In addition, we assessed demographic factors of GPs and patients and calculated associations regarding vaccination rates.

METHODS

This cross-sectional study was conducted within the context of thethe appropriateness of prescribing antibiotics in primary health care in Europe with respect to antibiotic resistance (APRES) project. Between November 2010 and July 2011, 40 GP practices attempted to recruit 200 patients to complete questionnaires about their influenza vaccination status and demographics. Statistical analyses included subgroup analyses and logistic regression models.

RESULTS

Data from 7269 patient questionnaires could be analyzed (3309 Austria and 3960 Croatia). The vaccination coverage rates were low (2009/2010: A 18.2 vs. C 20.9%, P < 0.001; 2010/2011: A 13.7 vs. C 18.6%; P < 0.001). The rates were found to be highest in persons aged 65 years and older (2009/2010: A 35.1 vs. C 49.5%, P < 0.001; 2010/2011: A 31.1 vs. C 45.7%, P < 0.001) and lowest in children (2009/2010: A 8.5 vs. C 2.0%, P < 0.001; 2010/2011: A 4.3 vs. C 1.6%, P = 0.002). Besides, demographics in the adjusted regression model for Austria being vaccinated was associated with consulting a female GP (OR, 4.20; P < 0.001) and in Croatia with five or more GP consultations per year (OR, 4.41; P < 0.001).

CONCLUSION

The vaccination coverage rates for Austria and Croatia were low, with the highest rates found in persons aged 65 years and older, showing that public coverage of the vaccination costs might increase vaccination rates. However, other factors seem to be relevant, including the engagement of GPs.

Cost-effectiveness analysis of a vaccination program for the prevention of herpes zoster and post-herpetic neuralgia in adults aged 50 and over in Germany

Herpes zoster (HZ; shingles) is a common viral disease that affects the nerves and surrounding skin causing a painful dermatomal rash and leading to debilitating complications such as, mainly, post-herpetic neuralgia (PHN). Currently, there is no effective treatment for HZ and PHN. The objective of this study was to assess the cost-effectiveness of a HZ vaccination program in Germany. An existing Markov Model was adapted to the German healthcare setting to compare a vaccination policy to no vaccination on a lifetime time-horizon, considering 2 scenarios: vaccinating people starting at the age of 50 or at the age of 60 years, from the perspective of the statutory health insurance (SHI) and the societal perspective. According to the perspective, vaccinating 20% of the 60+ German population resulted in 162,713 to 186,732 HZ and 31,657 to 35,793 PHN cases avoided. Corresponding incremental cost-effectiveness ratios (ICER) were 39,306 €/QALY from the SHI perspective and 37,417 €/QALY from a societal perspective. Results for the 50+ German population ranged from 336,468 to 394,575 HZ and from 48,637 to 56,087 PHN cases avoided from the societal perspective. Corresponding ICER were 39,782 €/QALY from a SHI perspective and 32,848 €/QALY from a societal perspective. Sensitivity analyses showed that results are mainly impacted by discount rates, utility values and use of alternative epidemiological data.The model indicated that a HZ vaccination policy in Germany leads to significant public health benefits and could be a cost-effective intervention. The results were robust and consistent with local and international existing literature.

Perceptions and behavioral responses of the general public during the 2009 influenza A (H1N1) pandemic: a systematic review

The public plays an important role in controlling the spread of a virus by adopting preventive measures. This systematic literature review aimed to gain insight into public perceptions and behavioral responses to the 2009 influenza A (H1N1) pandemic, with a focus on trends over time and regional differences. We screened 5498 articles and identified 70 eligible studies from PubMed, Embase, and PsychINFO. Public misconceptions were apparent regarding modes of transmission and preventive measures. Perceptions and behaviors evolved during the pandemic. In most countries, perceived vulnerability increased, but perceived severity, anxiety, self-efficacy, and vaccination intention decreased. Improved hygienic practices and social distancing were practiced most commonly. However, vaccination acceptance remained low. Marked regional differences were noted. To prevent misconceptions, it is important that health authorities provide up-to-date information about the virus and possible preventive measures during future outbreaks. Health authorities should continuously monitor public perceptions and misconceptions. Because public perceptions and behaviors varied between countries during the pandemic, risk communication should be tailored to the specific circumstances of each country. Finally, the use of health behavior theories in studies of public perceptions and behaviors during outbreaks would greatly facilitate the development of effective public health interventions that counter the effect of an outbreak.

Effectiveness of influenza vaccination of schoolchildren in the city of São Paulo, Brazil, 2009

BACKGROUND

Children play an important role in maintaining the transmission of influenza. Evidence suggests that vaccination of school-age children can reduce transmission to unvaccinated household contacts. We evaluated the direct and indirect effectiveness of the 2009 inactivated seasonal influenza vaccine in vaccinated schoolchildren and their unvaccinated household contacts.

METHODS

This was a double-blind cluster randomized trial involving 10 schools and 1742 schoolchildren as well as 5406 household contacts. The schools were randomly assigned to receive the influenza vaccine or the control vaccine. After vaccination, the schoolchildren and household contacts were followed for 6 months to identify cases of acute respiratory infection (ARI). Reverse-transcriptase polymerase chain reaction was performed for the diagnosis of influenza.

RESULTS

A total of 632 ARI cases were detected. Of those, 103 tested positive for influenza virus (influenza virus A[H1N1]pdm09 virus in 55 and seasonal influenza viruses in 48). The effectiveness of the vaccine in protecting against seasonal influenza virus infection was 65·0% for the household contacts (95% CI, 19·6-84·3) and 65·0% for the schoolchildren (95% CI, 20·9-84·5).

CONCLUSION

Vaccination of schoolchildren significantly protected them and their household contacts against seasonal influenza.

Extending the elderly- and risk-group programme of vaccination against seasonal influenza in England and Wales: a cost-effectiveness study

BACKGROUND

The present study aims to evaluate the cost-effectiveness of extending the pre-2013 influenza immunisation programme for high-risk and elderly individuals to those at low risk of developing complications following infection with seasonal influenza.

METHODS

We performed an economic evaluation comparing different extensions of the pre-2013 influenza programme to seven possible age groups of low-risk individuals (aged 2-4 years, 50-64 years, 5-16 years, 2-4 and 50-64 years, 2-16 years, 2-16 and 50-64 years, and 2-64 years). These extensions are evaluated incrementally on four base scenarios (no vaccination, risk group only with coverage as observed between 1995 and 2009, risk group and 65+, and risk group with 75% coverage and 65+). Impact of vaccination is assessed using a transmission model built and parameterised from a previously published study. The study population is all individuals of all ages in England and Wales representing an average total of 52.6 million people over 14 influenza seasons (1995-2009).

RESULTS

The influenza programme (risk group and elderly) prior to 2013 is likely to be cost effective (incremental cost effectiveness ratio: 7,475 £/QALY, net benefit: 253 M£ [15-829]). Extension to any one of the low-risk target groups defined earlier is likely to be cost-effective. However, strategies that do not include vaccination of school-aged children are less likely to be cost-effective. The most efficient strategy is extension to the 5-16 year age group while universal vaccination (extension to all low-risk individuals over 2 years) will achieve the highest net benefit. While extension to the 2-16 year age group is likely to be very cost effective, the cost-effectiveness of extensions beyond 2-16 years is very uncertain. Extension to the 5-16 year age group would likely remain cost-effective even without herd immunity effects to other age groups. As our study includes a strong historical component, our results depend on the efficacy of the influenza vaccine remaining at levels similar to the ones achieved in the past over a long-period of time (assumed to vary between 28% and 70% depending of the circulating strains and age groups).

CONCLUSIONS

Making use of surveillance data from over a decade in conjunction with a dynamic model, we find that vaccination of children in the United Kingdom is likely to be highly cost-effective, not only for their own benefit but also to reduce the disease burden in the rest of the community.

Associations between the prevalence of influenza vaccination and patient's knowledge about antibiotics: a cross-sectional study in the framework of the APRES-project in Austria

Background

This study aimed to identify associations between GP patient’s knowledge about the spectrum of effectiveness of antibiotics and the probability of vaccination against influenza. The underlying hypothesis was that individuals with an understanding that antibiotics are ineffective against viruses, common colds, and flu were more likely to be vaccinated than persons lacking this knowledge.

Methods

This cross-sectional study was conducted within the context of the European APRES project in Austria. Between November 2010 and July 2011, patients were recruited from GP practices to complete questionnaires about their knowledge about antibiotics and their influenza vaccination status. Statistical analyses included subgroup analyses and logistic regression models.

Results

Data of 3224 patients was analyzed, demonstrating that patients with better knowledge concerning antibiotics had a significantly higher likelihood of being vaccinated (OR 1.35, CI 95 % 1.18–1.54). While the overall vaccination rate was low (18.6 % in 2009/2010 and 14.0 % in 2010/2011), elderly compared to younger adults (OR 0.06 CI 95 % 0.03–0.13) and healthcare workers (OR 2.24, CI 95 % 1.42–3.54) demonstrated higher likelihood of vaccination. Additionally, female GPs had significantly more vaccinated patients than male GPs (OR 2.90, CI 95 % 1.32–6.40).

Discussion

There has been little prior study on the association between a patient’s knowledge of the effectiveness spectrum of antibiotics and influenza vaccination status. Given the public health imperative to increase annual prevalence of influenza vaccination, understanding this educational gap can improve specificity in counseling as well as vaccination rates. Ultimately, we found that those with a better knowledge on about antibiotics had a significantly higher likelihood of being vaccinated.

Conclusions

The results of this study demonstrate that vaccination prevalence is associated with patient’s knowledge about antibiotics. It can be concluded that one strategy to improve the overall low vaccination rates for seasonal influenza in Austria would be, particularly for male GPs, to have a specific discussion with patients about these circumstances by focusing on younger patients. Further, public health efforts could supplement in-office strategies to improve this area of health literacy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2297-x) contains supplementary material, which is available to authorized users.

Factors associated with uptake of influenza vaccine in people aged 50 to 64 years in Hong Kong: a case-control study

Background

In Hong Kong, people aged 50–64 years were added as a recommended priority group (recommended group) for influenza vaccination by the Department of Health (DH) starting from 2011/12 onwards. The coverage rate of influenza vaccination for this age group was suboptimal at 8.5 % in 2012/13. This study investigates the factors associated with the uptake of influenza vaccination among adults in Hong Kong aged 50–64 years.

Methods

A case–control study was conducted in communities by street intercept interviews from 17 July to 15 August 2013. Cases were adults aged 50–64 years who had received the influenza vaccine in 2011/12 or 2012/13, while controls were the same as the cases, except they had not received the influenza vaccine in 2011/12 or 2012/13. Multiple logistic regression analysis was performed on the data to explore the associations between vaccination status and the variables.

Results

Six hundred and four respondents in total were interviewed and included in the analysis. There were 193 cases (vaccinated) and 411 controls (non-vaccinated), with a case-to-control ratio of 1:2.1. The following were strongly associated with vaccination compared to other factors: ‘eligible for free government vaccine’ (OR6.38, 95 % CI, 3.43-11.87, p < 0.001); ‘willing to receive flu vaccination for free’ (OR4.84, 95 % CI, 2.13-11.03, p < 0.001); ‘perceived having severe or moderate symptoms when contracting flu’ (OR2.90, 95 % CI, 1.21-6.97, p = 0.02), and ‘convenient to reach a vaccination location’ (OR2.87, 95 % CI, 1.06-7.74, p = 0.04). The majority of the cases (80.8 %) and controls (93.9 %) were not aware that they belonged to a recommended group for influenza vaccination and most (>80 %) were willing to be vaccinated if it was free.

Conclusions

Factors related to free and convenient vaccination, the perception of the severity of symptoms when contracting influenza had a comparatively strong association with influenza vaccination uptake amongst 50–64 year olds, compared to other factors.

Systematic review of fever, febrile convulsions and serious adverse events following administration of inactivated trivalent influenza vaccines in children

In 2010, increased febrile convulsions (FC) occurred after administration of inactivated trivalent influenza vaccine (TIV) in Australia. We systematically reviewed the rates of fever, FC and serious adverse events (SAEs) after TIV, focussing on published and unpublished clinical trial data from 2005 to 2012, and performed meta-analysis of fever rates. From 4,372 records in electronic databases, 18 randomised controlled trials (RCTs), 14 non-randomised clinical trials, six observational studies and 12 registered trials (five RCTs and seven non-randomised) were identified. In published RCTs, fever ≥ 38 °C rates after first dose of non-adjuvanted TIV were 6.7% and 6.9% for children aged 6–35 months and ≥ 3 years, respectively. Analysis of RCTs by vaccine manufacturer showed pooled fever estimates up to 5.1% with Sanofi or GlaxoSmithKline vaccines; bioCSL vaccines were used in two non-randomised clinical trials and one unpublished RCT and were associated with fever in 22.5–37.1% for children aged 6–35 months. In RCTs, FCs occurred at a rate of 1.1 per 1,000 vaccinated children. While most TIVs induced acceptably low fever rates, bioCSL influenza vaccines were associated with much higher rates of fever in young children. Future standardised study methodology and access to individual level data would be illuminating.

Cross-Cultural Household Influence on Vaccination Decisions

Uptake of vaccination against seasonal influenza is suboptimal in most countries, and campaigns to promote vaccination may be weakened by clustering of opinions and decisions not to vaccinate. This clustering can occur at myriad interacting levels: within households, social circles, and schools. Given that influenza is more likely to be transmitted to a household contact than any other contact, clustering of vaccination decisions is arguably most problematic at the household level. We conducted an international survey study to determine whether household members across different cultures offered direct advice to each other regarding influenza vaccination and whether this advice was associated with vaccination decisions. The survey revealed that household members across the world advise one another to vaccinate, although to varying degrees, and that advice correlates with an increase in vaccination uptake. In addition, respondents in Japan, China, and the United States were less likely to offer advice to older adults than to the young, despite older adults' being the target age group for vaccination in both Far Eastern countries. Furthermore, advice was not primarily directed to household members within the age groups advised to vaccinate by national health policies. In Japan, advice was offered more to ages outside of the policy guidelines than inside. Harnessing the influence of household members may offer a novel strategy to improve vaccination coverage across cultures worldwide.

Public health impact and cost-effectiveness of intranasal live attenuated influenza vaccination of children in Germany

In 2011, intranasally administered live attenuated influenza vaccine (LAIV) was approved in the EU for prophylaxis of seasonal influenza in 2-17-year-old children. Our objective was to estimate the potential epidemiological impact and cost-effectiveness of an LAIV-based extension of the influenza vaccination programme to healthy children in Germany. An age-structured dynamic model of influenza transmission was developed and combined with a decision-tree to evaluate different vaccination strategies in the German health care system. Model inputs were based on published literature or were derived by expert consulting using the Delphi technique. Unit costs were drawn from German sources. Under base-case assumptions, annual routine vaccination of children aged 2-17 years with LAIV assuming an uptake of 50% would prevent, across all ages, 16 million cases of symptomatic influenza, over 600,000 cases of acute otitis media, nearly 130,000 cases of community-acquired pneumonia, nearly 1.7 million prescriptions of antibiotics and over 165,000 hospitalisations over 10 years. The discounted incremental cost-effectiveness ratio was <euro> 1,228 per quality-adjusted life year gained from a broad third-party payer perspective (including reimbursed direct costs and specific transfer payments), when compared with the current strategy of vaccinating primarily risk groups with the conventional trivalent inactivated vaccine. Inclusion of patient co-payments and indirect costs in terms of productivity losses resulted in discounted 10-year cost savings of <euro> 3.4 billion. In conclusion, adopting universal influenza immunisation of healthy children and adolescents would lead to a substantial reduction in influenza-associated disease at a reasonable cost to the German statutory health insurance system. On the basis of the epidemiological and health economic simulation results, a recommendation of introducing annual routine influenza vaccination of children 2-17 years of age might be taken into consideration.

The influence of partial public reimbursement on vaccination uptake in the older population: a cross-sectional study

Background

Flu vaccination is recommended annually for high risk groups. However, in Ireland, free access to vaccination is not universal for those in high risk groups; the vaccine and consultation are only free for those with a medical card, a means tested scheme. Few private health insurance policies cover the cost of attendance for vaccination in general practice. The aim was to examine the influence of this reimbursement policy on vaccination coverage among older adults.

Methods

Cross-sectional wave 1 data from The Irish Longitudinal Study on Ageing (TILDA) were analysed (2009–2011). TILDA is a nationally representative prospective cohort study of adults aged ≥50, sampled using multistage stratified clustered sampling. Self-reported entitlement to healthcare was categorised as 1) medical card only 2) private health insurance only, 3) both and 4) neither. The outcome was responses to ‘have you ever had a flu shot’. Multivariate logistic regression was used, adjusting for age and need.

Results

68.6% of those defined as clinically high-risk received the flu vaccination in the past (95% CI = 67-71%). Those with a medical card were almost twice as likely to have been vaccinated, controlling for age and chronic illness (OR = 1.9, 95% CI = 1.5-2.5, p = <0.001).

Conclusions

Having a medical card increased the likelihood of being vaccinated, independent of age and need. The mismatch between vaccination guidelines and reimbursement policy is creating unequal access to recommended services among high risk groups.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1356-7) contains supplementary material, which is available to authorized users.

2012/13 influenza vaccine effectiveness against hospitalised influenza A(H1N1)pdm09, A(H3N2) and B: estimates from a European network of hospitals

While influenza vaccines aim to decrease the incidence of severe influenza among high-risk groups, evidence of influenza vaccine effectiveness (IVE) among the influenza vaccine target population is sparse. We conducted a multicentre test-negative case-control study to estimate IVE against hospitalised laboratory-confirmed influenza in the target population in 18 hospitals in France, Italy, Lithuania and the Navarre and Valencia regions in Spain. All hospitalised patients aged ≥18 years, belonging to the target population presenting with influenza-like illness symptom onset within seven days were swabbed. Patients positive by reverse transcription polymerase chain reaction for influenza virus were cases and those negative were controls. Using logistic regression, we calculated IVE for each influenza virus subtype and adjusted it for month of symptom onset, study site, age and chronic conditions. Of the 1,972 patients included, 116 were positive for influenza A(H1N1)pdm09, 58 for A(H3N2) and 232 for influenza B. Adjusted IVE was 21.3% (95% confidence interval (CI): -25.2 to 50.6; n=1,628), 61.8% (95% CI: 26.8 to 80.0; n=557) and 43.1% (95% CI: 21.2 to 58.9; n=1,526) against influenza A(H1N1) pdm09, A(H3N2) and B respectively. Our results suggest that the 2012/13 IVE was moderate against influenza A(H3N2) and B and low against influenza A(H1N1) pdm09.

Low vaccination coverage among italian healthcare workers in 2013

Vaccination of healthcare workers (HCWs) reduces the risk of occupational infections, prevents nosocomial transmission and maintains healthcare delivery during outbreaks. Despite the European directive and national legislation on workers' protection, immunization coverage among HCWs has often been very low. In light of Italian National Vaccination Plan 2012-2014 recommendations, the aim of this study was to assess levels of immunization and factors influencing adherence to vaccinations needed for HCWs in Puglia region, South Italy. The study was conducted using an interview-based standardized anonymous questionnaire administered to hospital employees in the period November 2009-March 2011. A total of 2198 health professionals responded in 51/69 Apulian hospitals (median age: 45 years; 65.2% nurses, 22.6% doctors and 12.2% other hospital personnel). Vaccination coverage was 24.8% for influenza, 70.1% for hepatitis B, 9.7% for MMR, 3.6% for varicella, and 15.5% for Td booster. Receiving counselling from occupational health physicians (OHPs) was associated with influenza (OR = 1.8; 95%CI = 1.5-2.2; P < 0.001), hepatitis B (OR = 4.9; 95%CI = 3.9-6.3; P < 0.001), varicella (OR = 43.7; 95%CI = 18.9-101.7; P < 0.001), MMR (OR = 8.8; 95%CI = 4.1-18.6; P < 0.001) and tetanus (OR = 50.5; 95%CI = 30.1-88.3; P < 0.001) vaccine uptake.   OHPs should be trained with standard guidelines specific for healthcare settings and HCWs' risk groups to facilitate their crucial role in improving vaccine coverage among HCWs and increase awareness on the duty to protect both employees and patients.

Annual public health and economic benefits of seasonal influenza vaccination: a European estimate

BACKGROUND

Vaccination is currently the most effective means of preventing influenza infection. Yet evidence of vaccine performance, and the impact and value of seasonal influenza vaccination across risk groups and between seasons, continue to generate much discussion. Moreover, vaccination coverage is below recommended levels.

METHODS

A model was generated to assess the annual public health benefits and economic importance of influenza vaccination in 5 WHO recommended vaccination target groups (children 6 - 23 months of age; persons with underlying chronic health conditions; pregnant women; health care workers; and, the elderly, 65 years of age) in 27 countries of the European Union. Model estimations were based on standard calculation methods, conservative assumptions, age-based and country-specific data.

RESULTS

Out of approximately 180 million Europeans for whom influenza vaccination is recommended, only about 80 million persons are vaccinated. Seasonal influenza vaccination currently prevents an annual average of between 1.6 million and 2.1 million cases of influenza, 45,300 to 65,600 hospitalizations, and 25,200 to 37,200 deaths. To reach the 75% vaccination coverage target set by the EU Council Recommendation in 2009, an additional 57.4 million person would need to be vaccinated in the elderly and other risk groups. By achieving the 75% target rate set in EU-27 countries, average annual influenza- related events averted would increase from current levels to an additional +1.6 to +1.7 million cases, +23,800 to +31,400 hospitalization, +9,800 to +14,300 deaths, +678,500 to +767,800 physician visits, and +883,800 to +1,015,100 lost days of work yearly. Influenza-related costs averted because of vaccination would increase by an additional + €190 to + €226 million yearly, in vaccination target groups.

CONCLUSIONS

Full implementation of current influenza vaccination recommendations of 75% vaccination coverage rate (VCR) in Europe by the 2014-2015 influenza season could immediately reduce an important public health and economic burden.

Awareness and practices regarding zoonotic influenza prevention in Romanian swine workers

BACKGROUND

Swine workers may play a key role in transmission of zoonotic influenza viruses. At the same time, little is known about the extent and effectiveness of influenza prevention programs for these at-risk workers.

OBJECTIVES

To characterize practices and attitudes regarding zoonotic influenza transmission among swine workers in Romania.

METHODS

We conducted a convenience survey of swine workers in Romania. The confidential survey included questions about awareness of zoonotic influenza risk, work tasks performed, flu vaccination status, and reported influenza-like illness.

RESULTS

A total of 103 workers at seven farms completed the survey. The percentage of workers reporting concern about either contracting influenza from pigs or giving influenza to pigs was 78% and 70%, respectively. Although 60% of workers reported having a sick-leave policy at work, only 7% of workers reported receiving seasonal influenza vaccination during the past flu season. Only 5% of the workers reported flu-like illness during the past year while 3% of workers reported that pigs appeared sick with influenza over the same time period. The majority of workers reported using protective overalls and rubber boots during swine work, with lower rates of use of gloves. Reported use of respiratory protection was rare, and use of any personal protective equipment did not differ when pigs appeared ill.

CONCLUSIONS

Despite awareness and concern regarding zoonotic influenza, Romanian swine workers report low rates of influenza vaccine or respiratory protection. As part of global pandemic influenza preparedness, enhanced prevention programs for swine workers should address such gaps.

Vaccination coverage for seasonal influenza among residents and health care workers in Norwegian nursing homes during the 2012/13 season, a cross-sectional study

Background

WHO has set a goal of 75% vaccination coverage (VC) for seasonal influenza for residents and also recommends immunization for all healthcare workers (HCWs) in nursing homes (NHs). We conducted a cross-sectional study to estimate the VC for seasonal influenza vaccination in Norwegian NHs in 2012/2013 since the VC in NHs and HCWs is unknown.

Methods

We gathered information from NHs concerning VC for residents and HCWs, and vaccination costs for HCWs, using a web-based questionnaire. We calculated VC among NH residents by dividing the number of residents vaccinated by the total number of residents for each NH. VC among HCWs was similarly calculated by dividing the number of HCWs vaccinated by the total number of HCWs for each NH. The association between VC and possible demographic variables were explored.

Results

Of 910 NHs, 354 (38.9%) responded. Median VC per NH was 71.7% (range 0-100) among residents and 0% (range 0-100) among HCWs, with 214 (60%) NHs reporting that none of their HCWs was vaccinated. Median VC for HCWs in NHs with an annual vaccination campaign was 0% (range 0-53), compared to when they did not have an annual vaccination campaign 0% (range 0-12); the distributions in the two groups differed significantly (Mann–Whitney U, P = 0.006 two tailed).

Conclusion

Median influenza VC in Norwegian NHs was marginally lower than recommended among residents and exceptionally low among HCWs. The VC in HCWs was significantly higher when NHs had an annual vaccination campaign. We recommend that NHs implement measures to increase VC among residents and HCWs, including vaccination campaigns and studies to identify potential barriers to vaccination.

Healthcare workers as vectors of infectious diseases

Nosocomial infections cause considerable morbidity and mortality. Healthcare workers (HCWs) may serve as vectors of many infectious diseases, many of which are not often primarily considered as healthcare-associated. The probability of pathogen transmission to patients depends on several factors, such as the characteristics of a pathogen, HCW and patient. Pathogens with high transmission potential from HCWs to patients include norovirus, respiratory infections, measles and influenza. In contrast, human immunodeficiency virus (HIV) and viral hepatitis are unlikely to be transferred. The prevention of HCW-associated transmission of pathogens include systematic vaccinations towards preventable diseases, continuous education, hand hygiene surveillance, active feedback and adequate staff resources.

Seasonal influenza immunisation in Europe. Overview of recommendations and vaccination coverage for three seasons: pre-pandemic (2008/09), pandemic (2009/10) and post-pandemic (2010/11)

Since 2008, annual surveys of influenza vaccination policies, practices and coverage have been undertaken in 29 European Union (EU)/ European Economic Area (EEA) countries. After 2009, this monitored the impact of European Council recommendation to increase vaccination coverage to 75% among risk groups. This paper summarises the results of three seasonal influenza seasons: 2008/09, 2009/10 and 2010/11. In 2008/09, 27/29 countries completed the survey; in 2009/10 and 2010/11, 28/29 completed it. All or almost all countries recommended vaccination of older people (defined as those aged ≥50, ≥55, ≥59, ≥60 or ≥65 years), and people aged ≥6 months with clinical risk and healthcare workers. A total of 23 countries provided vaccination coverage data for older people, but only 7 and 10 had data for the clinical risk groups and healthcare workers, respectively. The number of countries recommending vaccination for some or all pregnant women increased from 10 in 2008/09 to 22 in 2010/11. Only three countries could report coverage among pregnant women. Seasonal influenza vaccination coverage during and after the pandemic season in older people and clinical groups remained unchanged in countries with higher coverage. However, small decreases were seen in most countries during this period. The results of the surveys indicate that most EU/EEA countries recommend influenza vaccination for the main target groups; however, only a few countries have achieved the target of 75% coverage among risk groups. Coverage among healthcare workers remained low.

Declining influenza vaccination coverage among nurses, Hong Kong, 2006-2012

Seasonal influenza vaccination of nurses in Hong Kong fell from 57% in 2005 to 24% in 2012, paralleling concern for adverse reactions associated with vaccination. Decreased acceptance of vaccination was most prominent among nurses who had less work experience and more frequent contact with patients.

Influenza vaccination coverage among medical residents: an Italian multicenter survey

Although influenza vaccination is recognized to be safe and effective, recent studies have confirmed that immunization coverage among health care workers remain generally low, especially among medical residents (MRs). Aim of the present multicenter study was to investigate attitudes and determinants associated with acceptance of influenza vaccination among Italian MRs. A survey was performed in 2012 on MRs attending post-graduate schools of 18 Italian Universities. Each participant was interviewed via an anonymous, self-administered, web-based questionnaire including questions on attitudes regarding influenza vaccination. A total of 2506 MRs were recruited in the survey and 299 (11.9%) of these stated they had accepted influenza vaccination in 2011-2012 season. Vaccinated MRs were older (P = 0.006), working in clinical settings (P = 0.048), and vaccinated in the 2 previous seasons (P<0.001 in both seasons). Moreover, MRs who had recommended influenza vaccination to their patients were significantly more compliant with influenza vaccination uptake in 2011-2012 season (P<0.001). "To avoid spreading influenza among patients" was recognized as the main reason for accepting vaccination by less than 15% of vaccinated MRs. Italian MRs seem to have a very low compliance with influenza vaccination and they seem to accept influenza vaccination as a habit that is unrelated to professional and ethical responsibility. Otherwise, residents who refuse vaccination in the previous seasons usually maintain their behaviors. Promoting correct attitudes and good practice in order to improve the influenza immunization rates of MRs could represent a decisive goal for increasing immunization coverage among health care workers of the future.