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Vaccination of health-care workers (HCWs) has been shown to reduce influenza
infection and absenteeism among HCWs,1 prevent mortality in their
patients,2 and result in financial savings to sponsoring health
institutions.3 However, influenza vaccination coverage among HCWs
in the United States remains low4,5,6; in 2003, coverage among
HCWs was 40.1% (CDC, unpublished data, 2005). This report describes strategies
implemented in three clinical settings that increased the proportion of HCWs
who received influenza vaccination. The results demonstrate the value of making
influenza vaccination convenient and available at no cost to HCWs.
In spring 2002, the California Department of Health Services, in collaboration
with local health departments, conducted a knowledge, attitudes, and behaviors
study of HCWs in 30 southern California nursing homes. This study determined
that problems with vaccine access and misconceptions regarding influenza and
the vaccine were associated with nonvaccination. The study results were used
to develop two interventions: (1) educational campaigns that emphasized the
seriousness of influenza and addressed employee misconceptions about influenza
and the vaccine (through employee in-services, fact sheets distributed with
employee paychecks, and informational handouts and posters); and (2) Vaccine
Days offering influenza vaccination free of charge to all HCWs on designated
days at the nursing home.
To evaluate the effectiveness of these interventions, the California
Department of Health Services conducted a controlled study in 70 southern
California nursing homes during the 2002-03 influenza season. Nursing homes
were selected by convenience sample and represented approximately 14% of nursing
homes in the areas from where they were selected. They were assigned to one
of four groups: (1) group A (n = 25), which conducted no interventions; (2)
group B (n = 15), which conducted an educational campaign; (3) group C (n
= 15), which held Vaccine Days; and (4) group D (n = 15), which conducted
both an educational campaign and held Vaccine Days.
Sixty-seven (95%) nursing homes completed the study, and 4,338 (61%)
of the 7,123 HCWs returned postintervention vaccination questionnaires; response
rates did not vary by study group but did range from 56% to 68% by nursing
home. According to preliminary analysis, when compared with the 27% vaccination
coverage in the control group (group A), Vaccine Days were effective in increasing
coverage when implemented in combination with the educational campaign (group
D) (53% coverage; adjusted odds ratio [AOR] = 3.54; 95% confidence interval
[CI] = 2.17-5.72) and when implemented alone (group C) (45%; AOR = 2.28; CI
= 1.30-3.98). However, an educational campaign alone (group B) did not significantly
increase HCW vaccine coverage (34%; AOR = 1.31; CI = 0.76-2.25).
During the early 1980s, influenza vaccination rates among employees
of the Minneapolis (Minnesota) Veterans Affairs Medical Center (VAMC) were
less than 25%. In 1985, as part of a comprehensive effort to increase vaccination
coverage among HCWs, VAMC initiated a Mobile Vaccination Cart Program. The
program maximized both convenience and efficiency through advertising to employees,
prescheduled vaccination times for employees in all wards and departments,
streamlined documentation of vaccination, provision of free vaccination, and
standing orders that authorized nurses to vaccinate VAMC employees.
The program is reviewed and endorsed each year by the VAMC Infection
Control Committee. One employee-health nurse and two infection-control nurses
set aside 2 weeks in mid-October to operate the mobile carts, which are stocked
with vaccine in syringes, vaccine information statements, sharps disposal
containers, alcohol hand rub, alcohol wipes, adhesive bandages, documentation
forms, and injectable epinephrine with orders for administration in the event
of an acute hypersensitivity reaction. Employees receive and are encouraged
to read information about vaccination before the cart comes to their area.
Inpatient wards are visited at the change of shift. Appointments are also
made for other clinical areas (e.g., laboratory and radiology) and for departments
with employees that might have direct patient contact (e.g., supply or housekeeping).
These schedules are posted, and employees are encouraged to “go to the
cart” if another time and location is more convenient than the scheduled
time for their work area. In addition, employees can also be vaccinated at
walk-in clinics for patients. A standardized, preprinted documentation form
further streamlines record-keeping.
Since the program was introduced in 1985, influenza vaccination rates
of VAMC HCWs increased steadily to 46% (1,475 of 3,177 employees) for the
1996-97 season and to 65% (1,950 of 3,008) for the 2003-04 season. The Mobile
Vaccination Cart Program enables nurses to answer questions and educate employees
about other strategies for preventing influenza transmission, such as proper
hand hygiene. VAMC attributed the steady increase in coverage to the cumulative
impact of ongoing education, communication, and access.
Yearly influenza vaccination of the approximately 25,000 employees at
Mayo Clinic in Rochester, Minnesota, is a challenge. During the 1999-2000
influenza season, 53.6% of Mayo staff members received influenza vaccination.
Since 2000, despite national vaccine shortages and delays, Mayo Clinic has
conducted intensive influenza vaccination efforts among its employees by making
vaccination increasingly convenient and by using gift incentives and peer
During the 2000-01 influenza season, Mayo Clinic offered free vaccine
to employees at large vaccination clinics in employee cafeterias and the employee
health service center. Immediately after these clinics, a Peer Vaccination
Program (PVP) enabling nurses to vaccinate coworkers at their worksites was
offered to all inpatient units. The PVP eliminated the expense and logistical
difficulty of establishing and staffing additional vaccination clinics and
made vaccination more convenient for HCWs. Under this combination of programs,
42.2% of all Mayo employees were vaccinated during the 2000-01 season, despite
barriers caused by vaccination shortage and delays. During the 2001-02 season,
continued shortages and delays prevented many employees from receiving vaccination.
As vaccine became available, employees in high-risk categories were vaccinated
first, mini-clinics were offered throughout the Mayo campus at convenient
locations, and 42.6% of all employees were ultimately vaccinated.
During the 2002-03 influenza season, an incentive program was added
to the influenza clinics. Employees vaccinated at one of the main clinics
could sign up for incentive gifts, such as movie tickets or health books,
which were distributed through a drawing after the influenza clinics were
held. In addition, electronic posters advertising the clinics were placed
at all staff entrances, cafeterias, and elevator banks. Vaccination coverage
for that season increased to 56.4%.
During the 2003-04 influenza season, Mayo Clinic placed additional emphasis
on education and vaccine accessibility, resulting in vaccination of 76.5%
of the 26,261 employees. As in previous years, vaccine was administered free
of charge at influenza clinics held in employee cafeterias and offered through
the PVP, and gift incentives were again provided. In December 2003, Mayo Clinic
began offering vaccination at departmental grand rounds, further eliminating
access and inconvenience barriers. Staff members were educated about the risk
for influenza, the need for vaccination, and the safety and efficacy of the
vaccine through newsletters, flyers, and poster presentations throughout the
vaccination season. Furthermore, influenza vaccine “champions”
(i.e., employee-health and infection-control staff members) promoted the importance
of influenza vaccination by conducting grand rounds, sending notices to all
employees by e-mail, attending meetings with nursing supervisors, staffing
a telephone hotline, and answering questions at the vaccination clinics.
AC Kimura, MD, JI Higa, MPH, C Nguyen, MPH, California Dept of Health
Svcs, Gardena; DJ Vugia, MD, California Dept of Health Svcs, Berkeley. M Dysart,
L Ellingson, L Chelstrom, MPH, J Thurn, MD, KL Nichol, MD, Minneapolis Veterans
Admin Medical Center; GA Poland, MD, J Dean, Mayo Clinic College of Medicine,
Rochester, Minnesota. KA Lees, MPH, DB Fishbein, MD, National Immunization
Influenza vaccination among U.S. HCWs increased from 10% in 1989 to
34% in 19974 and only slowly increased to 40% in 2003. The interventions
described in this report underscore the importance of making vaccination convenient
and available at no cost to HCWs. The study of southern California nursing
homes, the only controlled evaluation of efforts to influenza vaccination
coverage among HCWs, suggests that publicity and educational messages about
the importance of vaccination are only effective when combined with other
approaches to increase coverage. The results of the interventions conducted
by the Minneapolis VAMC and Mayo Clinic indicate that combining free vaccination
with programs to increase vaccine accessibility by using either mobile carts
or peer vaccination can overcome certain barriers to HCW influenza vaccination.
These findings were supported by a recent cross-sectional evaluation of interventions
for HCWs in neonatal and pediatric intensive-care units and hematology-oncology
units7 that demonstrated that use of mobile carts and educational
materials were associated with higher vaccination rates. The Mayo Clinic intervention
suggests that additional incentives might increase coverage further.
The results described in this report are consistent with other studies
demonstrating that organizational change (e.g., separate clinics devoted to
prevention), free vaccine, and gift incentives are particularly effective
methods of increasing vaccination among adults.8,9 Interventions
that were used to increase coverage among HCWs, including standing orders
and reducing out-of-pocket costs, both in conjunction with education, are
consistent with interventions strongly recommended by the Task Force on Community
The findings in this report are subject to at least two limitations.
First, ascertainment of vaccination status in the southern California study
was based on self-report, and only 61% of HCWs responded. Second, the VAMC
and Mayo Clinic studies did not control for other factors that might have
increased influenza vaccination; none of the studies were able to determine
what proportion of HCWs had risk factors other than their status as HCWs that
might have put them at increased risk for influenza and its complications.
Nonetheless, each of the interventions described in this report resulted in
vaccination rates exceeding national averages.
The influenza vaccine shortage during the 2004-05 season might have
prevented health-care institutions from implementing aggressive campaigns
for vaccination of HCWs. However, HCWs remain a high-priority group for vaccination.5 The National Foundation for Infectious Diseases has produced a call
to action to improve rates of influenza vaccination in HCWs.10 The
interventions described in this report suggest that making vaccination easily
accessible at no cost to HCWs and designated peer vaccination champions are
likely to increase vaccine coverage among HCWs.
REFERENCES: 10 available
Interventions to Increase Influenza Vaccination of Health-Care Workers—California and Minnesota. JAMA. 2005;293(14):1719–1721. doi:10.1001/jama.293.14.1719