Factors associated with staff and physician influenza immunization at a children's hospital in Ontario, Canada

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Abstract: In 2005, employees and physicians of the Children's Hospital of Eastern Ontario were surveyed about their experiences with and receipt of the 2003–2004 influenza vaccination. With a 29% response rate, 91% of respondents stated that they
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  © 2012 Deonandan et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access articlewhich permits unrestricted noncommercial use, provided the srcinal work is properly cited.International Journal of General Medicine 2012:5 719–724 International Journal of General Medicine Factors associated with staff and physician inuenza immunization at a children’s hospital in Ontario, Canada Raywat DeonandanGhada Al-SulaitiAsha GajariaKathryn N Suh School of Interdisciplinary HealthSciences, Faculty of Health Sciences,University of Ottawa, Ottawa,Ontario, CanadaCorrespondence: Raywat DeonandanSchool of Interdisciplinary HealthSciences, Faculty of Health Sciences,University of Ottawa, 35 University Pvt,Ottawa, Canada K1N 6N5Email raywat.deonandan@uottawa.ca Abstract: In 2005, employees and physicians o the Children’s Hospital o Eastern Ontario weresurveyed about their experiences with and receipt o the 2003–2004 inuenza vaccination. Witha 29% response rate, 91% o respondents stated that they had received the 2003–2004 vaccine,and physicians were the most likely to have done so (97.2%). Using logistic regression, the onlyactor signifcantly predictive o whether an employee or physician received the vaccine waswhether they had awareness o a previous ormal inuenza immunization campaign. Keywords: inuenza vaccination, sta, pediatric hospital Introduction Inection with seasonal inuenza can cause serious morbidity and mortality inhospitalized patients. 1 The reported eectiveness o the modern trivalent inuenzavaccine ranges rom 74% 2 to 89.4%, 3 depending upon the population and study type.Immunization o health care workers is a proven strategy or reducing the mortality o vulnerable populations in an institutional setting. 4,5 While inuenza can be transmit-ted to patients by inected health care providers, uptake o the vaccine by health careworkers is not at an expected or acceptable level. Asymptomatic inection is com-mon, reported to occur in up to 23% o health care workers. 6 In addition, health careworkers continue to report or work despite the presence o inuenza symptoms. 7  A recent review o Australian studies showed the rate o Australian health care worker immunization to be 16.3%–58.7%, 8 with higher rates reported in hospitals with activevaccination campaign programs.Beyond the obvious and immediate benefts to the vulnerable patient populationare the measurable economic benefts that immunization provides. Health care workerswho are vaccinated against inuenza are less likely to acquire inection, and even i they become inected, the symptoms are likely to be less severe. Thereore, vaccina-tion results in reduced sta absenteeism and illness. 9 Given that uptake o the inuenza vaccine by health care workers in most hospitalsettings is less than optimal, it is important to understand the actors that are associated with a ailure to, or unwillingness to, become immunized. A programmatic responsecan then target these determinants more eectively. 10 At the Children’s Hospital o Eastern Ontario (CHEO) in Ottawa, Ontario, aninuenza immunization campaign or employees and physicians is conducted byOccupational Health and Saety every year. The availability o the vaccine is adver-tised through several media, including a reminder included in employees’ pay stubs. Dovepress submit your manuscript |www.dovepress.com Dovepress 719 ORIGINAL RESEARCH open access to scientifc and medical research Open Access Full Text Article http://dx.doi.org/10.2147/IJGM.S33362 Number of times this article has been viewed This article was published in the following Dove Press journal:International Journal of General Medicine22 August 2012  International Journal of General Medicine 2012:5 Prior to this survey, seasonal inuenza immunization ratesamong CHEO sta and physicians were 63% in 2001–2002and 69% in 2002–2003. In 2003–2004, the season o interestor this survey, the immunization rate was 77%. This studydescribes the knowledge, attitudes, and behaviors associ-ated with receipt o the inuenza vaccination during the2003–2004 inuenza season. Materials and methods The CHEO is a 150-bed tertiary-care, academic pediatricacute care acility serving eastern Ontario and westernQuebec. During the study period, 1906 sta and 150 physicians worked at CHEO as their primary place o employ-ment. A 10-minute, sel-administered, bilingual (English and French) survey was developed and piloted among small groupso employees and physicians or comprehensibility and ow.The survey was delivered to all CHEO sta with pay stubs,and to physicians electronically by email, in October 2005.The survey consisted o 28 questions, the most pertinent o which were, “Did you get the inuenza vaccine last all or winter (2003–2004)?”, “Do you think the inuenza vaccineis eective in preventing inuenza?”, and “Do you think theinuenza vaccine can give you the inuenza?” Reminderswere sent out 2 and 4 weeks ater the frst mailing.All employees o the hospital were invited to participatein the study. Health care providers who were not physiciansor nurses (ie, physiotherapists, occupational therapists, and rehabilitation therapists) were combined into the category o “other health care providers”. Employees in nonclinical roles(eg, personal support workers, administrative sta, ood ser-vices employees, researchers, and students) were combined into the category called “nonhealth care workers”.Data rom completed surveys were entered into an elec-tronic database. Duplicate entries were identifed by scanningor repeated unique identifers (name or identifcation badgenumber). Unique identifers were subsequently deleted toretain respondent anonymity. Accuracy o data entry wasvalidated by duplicate entry o 10% o completed surveys.Basic requencies, cross-tabulations, and  t- tests werecomputed using SPSS version 12.0 (SPSS Inc, Chicago,IL), with  P  values or Fisher’s Exact test computed usingthe open source computing package “R”. A logistic regres-sion analysis was perormed using a backwards eliminationmethod to model covariates associated with sel-reported immunization status in 2003–2004. An interaction term wasincluded to control or the relationship between respondentage and length o employment with the hospital. This studywas approved by the CHEO research ethics board. Results In total, 588 surveys were returned rom 2056 sta and  physicians (response rate 29%), 84.5% o whom wereemale. Respondents had a mean age o 31.0 years and anaverage length o employment at CHEO o 12.6 years. The10 occupation categories srcinally asked or in the surveywere collapsed into our, due to cell sample size constraints(Table 1). Ninety-one percent o respondents stated that theyhad received the inluenza vaccine in 2003–2004, and six respondents did not answer the question. Only 6.5%reported that they believed the vaccine could actuallycause inuenza. Table 2 summarizes the responses to the primary questions across the categories o respondents’occupations. Physicians, although small in number, werethe most likely to have been vaccinated (97.2%), and werealso most likely to have been vaccinated prior to the currentseason (94.3%).Those who were nonimmunized were more likely to think the vaccine causes inuenza (14.6% versus 6.5%,  P    , 0.05),less likely to think the vaccine was eective (44.9% versus68.5%,  P    , 0.001) and more likely to think that ever is a possible side eect (93.3% versus 75.8%,  P    = 0.012). Thosewho were immunized were more likely to consider theinuenza vaccine to be a “proessional obligation” (78.4%versus 34.7%,  P    , 0.001). There was no statistically sig-nifcant dierence between those who were immunized and those who were not with respect to expecting side eects o  paralysis, pain, or rash.Table 3 presents a summary o the reasons that non-immunized respondents provided or not receiving the submit your manuscript |www.dovepress.com Dovepress Dovepress 720 Deonandan et al Table 1 Distribution of srcinal and recoded professionalcategories Collapsed andrecoded categoriesOriginal professionalcategoriesn% PhysicianNurseOther health careproviderNonhealth careworkerNo responseStaff physicianNurseOther health care provider(physiotherapist, occupationaltherapist, respiratory technician)Personal support assistantsHospital administrationClericalSupport staff (eg, food services)ResearchStudentOtherNo response3723010021836.339.117.037.10.5Totals588100.0  International Journal of General Medicine 2012:5 inuenza vaccine. Most common were doubts about theeectiveness o the ormulation and ear o side eects, both reported in 24.2% o those who were nonimmunized.Table 4 summarizes the statistically signifcant univariaterelationships between anticipated predictive actors and receipt o immunization. Table 5 shows adjusted odds ratiosater logistic regression analysis. Not surprisingly, the major-ity o those who were immunized in 2003–2004 were muchmore likely to report that they would seek vaccination in thesubsequent season (  P    , 0.001). However, being immunized in the previous season was not associated with being immu-nized currently (  P    = 1.000). Discussion Promoting inuenza vaccination uptake among health careworkers is important or a host o clinical, ethical, and eco-nomic reasons. The protection o patients, many o whomare at risk o serious complications o inuenza, remainsthe most common argument. While there is some evidencethat immunization o health care workers, in the absenceo a campaign to immunize patients also, does not coner much o an advantage in curbing institutional inectionrates, 11 other studies have demonstrated that health careworker immunization is associated with reduced mortalityin long-term care acilities, 12,13 and with reduced healthservice usage and inuenza-like illness among residents/ patients at the institution in question. 14 Regardless, worker absenteeism due to seasonal inuenza has been identifed asa drain on already stretched clinical care budgets o many jurisdictions. 15 The costs o absenteeism and o addressingan institutional outbreak essentially draw resources romother health needs. As a result, any attempt to increase healthcare workers’ uptake o the seasonal inuenza vaccine isreadily deensible.Previous attempts to identiy barriers to uptake o thevaccine by proessionals have consistently identifed sev-eral actors, ie, ear o needles, 7,16–18 inconvenience, 1,16,19  ear o adverse events, 1,17–21 and a belie that the vaccine isineective. 1,7,17,19–21 Our data confrm these observations.Additionally, avoidance o medication 7,17,20 and a belie in being in a “low-risk” population 1,7,17,19,21 have been identi-fed as contributing actors, but were not explored in the present study.By logistic regression analysis, only one actor, ie, aware-ness o previous inuenza immunization campaigns, wasassociated with receipt o inuenza vaccine. This suggeststhat the commonly accepted barriers to vaccine uptake, ie,inconvenience and a ear o potential adverse events, can be inuenced in a proessional environment with a ormalcampaign ocused on proessional obligations and continuingemployee education. Table 4 Statistically signicant univariate associations between predictive factors and receipt of vaccine in the 2003–2004 season Predictive factor (all positivelyassociated with vaccination) P  (Fisher’s exact testor two-sample t -test) Increasing age0.006 ( t  -test)Increasing years working at CHEO , 0.001 ( t  -test)Had memory of the previous vaccinationcampaign , 0.001 (Fisher’s exact test) The hours of the clinic were convenient , 0.001 (Fisher’s exact test) Abbreviation: CHEO, Children’s Hospital of Eastern Ontario. submit your manuscript |www.dovepress.com Dovepress Dovepress 721 Staff inuenza immunization at a children’s hospital Table 2 Distribution of responses to primary questions by occupation type Occupation Received the infuenza vaccination in 2003–2004n (%)Believes that thevaccine is effectiven (%)Believes that the vaccine can cause infuenza  n (%)YesNoUnsureYesNoUnsureYesNoUnsure Physician35 (97.2)1 (2.8)033 (89.2)1 (2.7)3 (8.1)037 (100)0Nurse212 (93.0)16 (7.0)0144 (63.7)15 (6.6)67 (29.6)13 (5.7)205 (90.3)5 (2.2)Other health care provider91 (92.9)7 (7.1)064 (63.0)3 (3.0)34 (34.0)3 (3.0)92 (92.9)3 (3.0)Nonhealth care workerTotal190 (87.6)25 (11.5)2 (0.9)144 (67.0)16 (7.4)55 (25.6)26 (12.0)187 (86.6)2 (0.9)Total (all professions)528 (91.2)49 (8.5)2 (0.3)384 (66.4)35 (6.1)159 (27.5)42 (7.3)521 (90.0)10 (1.7) Table 3 Respondents’ top stated reasons for not getting theinuenza vaccination in 2003–2004 Top reasons reported for not getting the infuenza vaccine in 2003–2004 n% Other1727.4Belief that the vaccine does not work1524.2Afraid of side effects1524.2Never got around to it1016.1Allergic812.9Belief that it weakens/harms the immune system711.3Pregnant or nursing58.1 Belief that the vaccine can cause inuenza 46.5No contact with patients46.5  International Journal of General Medicine 2012:5 The extent to which these results can be used to inormuture vaccination campaigns depends, o course, upon thespecifc profle o the institution in question, ie, its history o vaccination campaigns, the degree to which employees have been exposed to inuenza education, and the occupationalmix o the sta. However, what is possibly universal is thatreinorced knowledge o the existence o an inuenza cam- paign is a (strong) predictor o immunization. Whether thatreinorcement comes in the orm o a ormal reminder, asin the notes included with employees’ paychecks, througheorts to make each campaign memorable, or through eortsto optimize and publicize the convenience o being immu-nized, reinorcing awareness o an inuenza immunizationcampaign is an eective strategy or maximizing uptake.Our data do not reect the experiences o a populationhaving undergone the media ocus o the H1N1 outbreak.That season may have resulted in two competing trends,ie, an increased awareness o the need or, and availabilityo, inuenza vaccination; and ironically perhaps a greater distrust o the health communications surrounding the need or vaccination, given the comparatively ew numbers o serious H1N1 cases that arose in the US relative to someo the dire predictions that were made. Given that our data predate those experiences, any reections on the impact o H1N1 on new attitudes toward u immunization would bestrictly speculative.Given our low physician response rate, we cannot makeany conclusions regarding very high immunization ratesamong this occupational group. Our overall low response ratemight have been exacerbated by the decision to collect namesand identifcation numbers, thus providing a disincentive or  participation. The hospital’s overall 23% nonvaccination ratecompared with an 8.5% rate in our sample hints at somethingo a selection bias in our data, to the extent that those whowere vaccinated were also more likely to have completed our survey. Thereore, any wisdom extracted rom these datamust be careully considered. However, our results contrastwith those o Kara et al 22 who ound that 33.7% o pediatricresidents thought that the inuenza vaccine was “unneces-sary”, with 69% o those who experienced minor adverseeects (such as arm soreness) expressing doubt that theywould accept the vaccine in subsequent years due to thoseadverse events. Concern or adverse events, however minor,appears to be a consistently prominent actor in dissuadinghospital workers rom being immunized. This is disappoint-ing, because it is hoped that health care workers would havean experienced and inormed perspective that would convincethem o the benefts o tolerating generally minor adverseevents as the price or immunity.More concerning still in the present study is the fndingthat more than a third o nurses who responded doubted thevaccine’s eectiveness, while almost 8% believed that it caneven cause inuenza. This clearly speaks to a need or deeper and continuing proessional education. Fortunately, noneo the nonimmunized nurses cited a belie in the vaccine’sability to cause disease as a reason or their immunizationstatus. Instead, nonimmunized nurses were more likely to beconcerned about allergies, potential eects on pregnancies(or concerning a pregnancy), or adverse events.The comparatively lower vaccination rates amongnonhealth care workers, relative to that o clinicians, wasnot surprising, given the likelihood that that group had received less ormal education about the benefts and riskso vaccination. Future studies are advised to explore someo the demographic actors aecting their decision to oregovaccination, such as religious belies, country o birth, and  possibly more individualized personal experiences.Our fndings may not be generalizable to other healthcare acilities and are subject to several limitations. Our response rate was less than 30%; respondents may not have been representative o all sta and physicians at CHEO; and since most respondents had in act been immunized, the pos-sibility o a degree o selection bias in our results persists.Moreover, the survey was not administered immediatelyater the 2003–2004 inuenza immunization season and respondents may have been subject to recall bias. CHEO is asmall, single-site pediatric acility which has historically had relatively high sta and physician inuenza immunizationrates. Despite the somewhat unique nature o CHEO, somewisdom can be garnered rom these results or the purposeso designing immunization campaigns in other acilities, most Table 5 Statistically signicant associations between predictive factors and receipt of vaccine in the 2003–2004 season, afterapplication of backwards elimination logistic regression Predictive factorAdjusted OR and 95% CI Belief that the vaccine can cause fever0.2 (0–0.9)Increasing age1.1 (1.0–1.1)Respondent occupation • Nurse1.2 (0.1–10.4) • Other health provider1.7 (0.1–22.2) • Nonhealth care worker0.4 (0.1–3.4) • Physician (reference category)1.0Knowledge of vaccination campaignvia letter with paycheck 0.3 (0.1–0.8)Knowledge of previous vaccinationcampaign(s)4.0 (1.5–10.6) Abbreviations: CI, condence interval; OR, odds ratio. submit your manuscript |www.dovepress.com Dovepress Dovepress 722 Deonandan et al  International Journal of General Medicine 2012:5 notably the lesson that both the convenience o immunizationand the regularity o reminders o a vaccination campaigncan contribute to increased compliance rates.Overall, the survey indicates a high degree o sel-reported vaccine compliance, especially among those most likely to provide direct care to patients. The degree o misinormationreected by respondents is relatively small, and is less evidentamongst the more clinical groups. However, misconceptionsabout the nature and risks posed by the inuenza vaccineare still prevalent among a small but noticeable raction o clinical sta. This is concerning because these individualsare likely to be relied upon to communicate the nature o the vaccine to other stakeholders eectively and accurately,including patients and their amilies.One seemingly contradictory fnding was that knowledgeabout the vaccination campaign via a letter in the paycheck was predictive o not having been vaccinated, while memoryo previous campaigns was predictive o having received thevaccination. This seems to reect a tendency to dismiss paper notices, while emphasizing the importance o remembered experiences.Despite our low response rate, the results herein suggestthat awareness o a ormal institutional inuenza immuniza-tion campaign or sta and physicians was associated withreceipt o inuenza immunization, and therein lies the mostnovel aspect o our study. Indirectly, this would suggest thatour current inuenza vaccine campaign strategy is largelyeective, though ails to elicit compliance among a minor-ity o sta and physicians. However, given our population’soverall immunization rates, the total eect o the campaignis nonetheless insufcient, especially when considering thevulnerable nature o the hospitalized patient population.Further appropriate strategies to increase vaccinationuptake need to be explored, including expanded educationalcampaigns, reminders that are sent outside o just the peak season, and possibly even the consideration o mandatoryvaccination requirements. Acknowledgment The authors would like to thank the sta and administration o CHEO or their cooperation in the undertaking o this study. Disclosure The authors report no conict o interest in this work. References 1. Eiseneld L, Perl L, Burke G, et al. Lack o compliance with inuenzaimmunization or the caretakers o neonatal intensive care unit patients.  Am J Infect Control  . 1994;22:307–311.2. 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Inuenza vaccinationo healthcare workers: institutional strategies or improving rates.  N C Med J  . 2004;65:323–328. 22. Kara A, Devrim I, Celik T, et al. Inuenza vaccine adverse eventand eect on acceptability in pediatric residents.  Jpn J Infect Dis .2007;60:387–388. submit your manuscript |www.dovepress.com Dovepress Dovepress 723 Staff inuenza immunization at a children’s hospital
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