Worksite: Seasonal Influenza Vaccinations Using Interventions with Actively Promoted, Off-Site Vaccinations Healthcare Workers

The CPSTF finding is based on evidence from a systematic review of 1 study (search period through March 2008). The review was conducted on behalf of the CPST by a team of specialists in systematic review methods, and in research, practice, and policy related to worksite health promotion.

Interventions with actively promoted, off-site influenza vaccinations encourage workers in healthcare worksites to obtain influenza vaccinations in a location other than that in which they normally work using any of a variety of approaches. These include providing vouchers or leave time, conducting health education sessions, and sending reminders about the vaccination. The intervention must be promoted through formal worksite announcements, such as newsletters, e-mails, paycheck inserts, or posters in the worksite and may include additional components.

One study was included in the review.

• Authors reported small, non-significant findings when comparing the treatment and control groups: 21.9 percent versus 21.0 percent (p=.91) among primary healthcare teams and 10.2 percent versus 5.6 percent (p=.34) among nursing homes.

An economic review of this intervention was not conducted because CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because CPSTF did not have enough information to determine if the intervention works.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for these interventions to promote seasonal influenza vaccinations among healthcare workers: on-site, free, actively promoted vaccinations; and actively promoted off-site vaccinations.

Although the body of evidence is strong, the field would benefit from research into the following questions:

• How do the observed successes in large hospitals and long-term care facilities translate to coalitions of smaller healthcare facilities that may share health promotion resources or family practice clinics that operate on their own?
• In what ways do current interventions with on-site, no-cost, actively promoted influenza vaccinations create, add to, reduce, or eliminate disparities among sub-groups of HCP?
• What additional barriers should implementers address to achieve influenza vaccination coverage of greater than 90% among HCP?

Finally, as was shown in the review for general worksites, the overall body of knowledge for off-site, promoted interventions is weak. With only one study with small and non-significant effect measure, in spite of the study’s use of rigorous methods, in the body of literature that analyzed this approach, we were unable to conclude on its effectiveness.

The included study was a randomized, controlled trial that evaluated the effectiveness of health education approaches to increase influenza vaccinations off-site with primary care providers (as opposed to the entire HCW population).

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table
Contains evidence from the following reviews: on-site, free, actively promoted vaccinations, and actively promoted, off-site vaccinations for healthcare workers

The following list of included studies is for these interventions to promote seasonal influenza vaccinations among healthcare workers: on-site, free, actively promoted vaccinations; and actively promoted off-site vaccinations.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Bannerman B, Schram K. Influenza immunization program in long term care facilities. Can J Infect Control 1992;7(1):13-5.

Bautista D, Vila B, Uso R, Tellez M, Zanon V. Concise communications. Predisposing, reinforcing, and enabling factors influencing influenza vaccination acceptance among healthcare workers. Infection Control and Hospital Epidemiology 2006;27(1):73-7.

Bertin M, Scarpelli M, Proctor AW, et al. Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program. Am J Infect Control 2007;35(1):33-7.

Bertin M, Scarpelli M, Proctor A, Sharp J, Robitson E. Using the Intranet to document healthcare worker (HCW) declination and participation in a mandatory influenza vaccination program. Am J Infect Control 2006;34(5):E49-E50.

Boersma B, Rhames T, Keegan JM. Additional cost savings of an effective employee influenza program on prevention of nosocomial influenza. Am J Infect Control 1999;27(2):177-8.

Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. The Lancet 2000;355(9198):93-7.

Chance J, Williamson S. A user-friendly approach to improving healthcare worker influenza vaccination compliance. Am J Infect Control 2005;33(5):e62-e50.

Cooper E, O’Reilly M. A novel staff vaccination strategy. Infect Control Hosp Epidemiol 2002;23(5):232-3.

de Juanes JR, Garcia de Codes A, Arrazola MP, Jaen F, Sanz MI, Gonzalez A. Influenza vaccination coverage among hospital personnel over three consecutive vaccination campaigns (2001-2002 to 2003-2004). Vaccine 2007;25(1):201-4.

Dunais B, Saccomano C, Mousnier A, Roure MC, Dellamonica P, Roger PM. Influenza vaccination: impact of an intervention campaign targeting hospital staff. Infect Control Hosp Epidemiol 2006;27(5):529-31.

Centers for Disease Control and Prevention. Interventions to increase influenza vaccination of health-care workers–California and Minnesota. MMWR – Morbidity & Mortality Weekly Report 2005;54(8):196-9.

Eagan J, Lim S, Odishoo A, Wallace H, Langtry A, Sepkowitz K. Novel approaches to improving employee influenza vaccination compliance. Am J Infect Control 1999;27(2):206-165.

Fitzgerald TA, Jourdan DR, Sholtz LA, Murphy EM, Poppert DW. Influenza: Lessons learned from an outbreak, post-exposure prophylaxis and vaccination campaigns. Am J Infect Control 2006;34(5):E88-E73.

Gemeinhart N, Carroll C, Gavwiner C, et al. Development of a best practice for healthcare worker influenza vaccination. Am J Infect Control 2004;32(3):E97-E29.

Girasek DC. Increasing hospital staff compliance with influenza immunization recommendations. Am J Public Health 1990;80(10):1272-3.

Gornick W, Nelson C, Scanlan G, Lang DJ. “Mandatory” influenza immunization (FluImm) of healthcare workers (HCW) at Children’s Hospital of Orange County (CHOC). Am J Infect Control 2007;35(5):E99-E40.

Hall KL, Holmes SS, Evans ME. Increasing hospital employee participation in an influenza vaccine program. Am J Infect Control 1998;26(3):367-8.

Harbarth S, Siegrist CA, Schira JC, Wunderli W, Pittet D. Influenza immunization: improving compliance of healthcare workers. Infect Control Hosp Epidemiol 1998;19(5):337-42.

Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: Cluster randomised controlled trial. BMJ: British Medical Journal 2006;333(7581):No.

Kimura AC, Nguyen CN, Higa JI, Hurwitz EL, Vugia DJ. The effectiveness of vaccine day and educational interventions on influenza vaccine coverage among health care workers at long-term care facilities. Am J Public Health 2007;97(4):684-90.

Klochnyk B, Klein J. How a Canadian accute care hospital acheived 84% voluntary staff influenza vaccination rate. Infect Control Hosp Epidemiol 2000;Feb:86.

Lee HY, Fong YT. On-site influenza vaccination arrangements improved influenza vaccination rate of employees of a tertiary hospital in Singapore. Am J Infect Control 2007;35(7):481-3.

Leitmeyer K, Buchholz U, Kramer M, et al. Influenza vaccination in German health care workers: effects and findings after two rounds of a nationwide awareness campaign. Vaccine 2006;24(47-48):7003-8.

Lopes MH, Sartori AM, Mascheretti M, et al. Intervention to Increase Influenza Vaccination Rates Among Healthcare Workers in a Tertiary Teaching Hospital in Brazil. Infection Control and Hospital Epidemiology 2008;29(3):285-6.

Maher AC, Foley M, Castello F, Christie E. Focus on the myths: An approach to improving healthcare worker influenza immunization rates. Am J Infect Control 2006;34(5):E107-EE73.

Mayoryk SA, Levy SM. Incentive program increases employee influenza vaccine compliance at a chronic hospital/long-term care facility. Am J Infect Control 2006;34(5):E49-214.

McCullers JA, Speck KM, Williams BF, Liang H, Mirro J Jr. Increased influenza vaccination of healthcare workers at a pediatric cancer hospital: results of a comprehensive influenza vaccination campaign. Infect Control Hosp Epidemiol 2006;27(1):77-9.

Nace DA, Hoffman EL, Resnick NM, Handler SM. Achieving and sustaining high rates of influenza immunization among long-term care staff. J Am Med Dir Assoc 2007;8(2):128-33.

Ohrt CK, McKinney WP. Achieving compliance with influenza immunization of medical house staff and students: A randomized controlled trial. Journal of the American Medical Association 1992;267(10):1377-80.

Olson K, Beckwith S. Strategies to increase employee participation in the annual employee influenza vaccination clinic. Am J Infect Control 1991;19(2):113-84.

Parry MF, Grant B, Iton A, Parry PD, Baranowsky D. Influenza vaccination: a collaborative effort to improve the health of the community. Infect Control Hosp Epidemiol 2004;25(11):929-32.

Poland GA. Influenza vaccine prevented influenza infection in health care workers. Evidence-Based Medicine 1999;4:140.

Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004;25(11):923-8.

Samms D, Reed K, Lee T, Barill S, Branham D. Achieving a corporate goal for influenza vaccination using nurse champions. Am J Infect Control 2004;32(3):E7-E8.

Sanchez D, Breland BD, Pinkos L, Eagle A, Nowlin D, Duty L. Pharmacist-run influenza immunization clinic for health workers. Am J Health-Syst Pharm 2003;60(3):241-3.

Sand KL, Lynn J, Bardenheier B, Seow H, Nace DA. Increasing influenza immunization for long-term care facility staff using quality improvement. J Am Geriatr Soc 2007;55(11):1741-7.

Sartor C, Tissot-Dupont H, Zandotti C, Martin F, Roques P, Drancourt M. Use of a mobile cart influenza program for vaccination of hospital employees. Infect Control Hosp Epidemiol 2004;25(11):918-22.

Scheifele DW. Evaluation of adverse events after influenza vaccination in hospital personnel.Canadian Medical Association Journal; CMAJ 1990;142(2):127-30.

Shannon SC. Community hospitals can increase staff influenza vaccination rates. Am J Public Health 1993;83(8):1174-5.

Smedley J, Palmer C, Baird J, Barker M. A survey of the delivery and uptake of influenza vaccine among health care workers. Occupational Medicine-Oxford 2002;52(5):271-6.

Song JY, Park CW, Jeong HW, Cheong HJ, Kim WJ, Kim SR. Effect of a hospital campaign for influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol 2006;27(6):612-7.

Tannenbaum TN, Thomas D, Baumgarten M, Saintonge F, Roban I. Evaluation of an influenza vaccination program for nursing home staff. Canadian Journal of Public Health 1993;84(1):60-2.

Tapiainen T, Bar G, Schaad UB, Heininger U. Influenza vaccination among healthcare workers in a university children’s hospital. Infection Control and Hospital Epidemiology 2005;26(11):855-8.

Thomas DR, Winsted B, Koontz C. Improving neglected influenza vaccination among healthcare workers in long-term care. Journal of the American Geriatrics Society 1993;41(9):928-30.

Vaughan JZ. Healthcare worker participation in influenza vaccination. Am J Infect Control 2006;34(5):E15-214.

Weinstock DM, Eagan J, Malak SA, et al. Control of influenza A on a bone marrow transplant unit. Infection Control and Hospital Epidemiology 2000;21(11):730-2.

Yassi A, Kettner J, Hammond G, Cheang M, McGill M. Effectiveness and cost-benefit of an influenza vaccination program for health care workers. Can J Infect Dis 1991;2(3):101-8.

The following outlines the search strategy used for these reviews of interventions to promote seasonal influenza vaccinations among healthcare and non-healthcare workers: on-site, free or reduced cost, actively promoted vaccinations; and actively promoted off-site vaccinations.

With the assistance of a CDC librarian, the team searched for published studies in the following databases: PubMed, PsychInfo, CINAHL, Web of Science, Science Direct, Embase, CSA Illumina (Cambridge Scientific Abstracts), Proquest, Cochrane Library, Google Scholar, Sociological Abstracts, EconLit, and Global Health. The team also searched bibliographic reference lists and accepted suggestions of studies from members of the team.

The team considered studies for inclusion if they:

• Were primary research published in a journal or a technical or government report
• Were published in English
• Met minimum research quality criteria for study design and execution specifically, using designs with before-and-after comparisons in the intervention group or comparisons across two groups receiving different levels of intervention
• Evaluated an intervention designed to increase seasonal influenza vaccination coverage, conducted and promoted among workers in a healthcare worksite
• Evaluated change in seasonal influenza vaccination coverage, morbidity, mortality, or worker productivity associated with the intervention.

The team searched for and accepted for possible inclusion studies published through March 2008.

Database: MEDLINE (OVID) 722 results

exp Influenza, Human/ or (influenza or flu).mp
AND
exp Vaccination/ or exp Immunization Programs/ or exp Immunization/ or exp
Vaccines/ or (immuniz$ or vaccin$ or inoculat$ or jab or jabs).mp
AND
exp Work/ or exp Workplace/ or exp Health Personnel/ or exp Employment/ or
(worksite or workplace or work or employee or worker or employer or working).mp

Database: PSYCINFO (Ovid) 29 results

exp INFLUENZA/ or (influenza or flu).mp
AND
exp Immunization/ or (immuniz$ or vaccin$ or inoculat$ or jab or jabs).mp
AND
exp Personnel/ or exp Employment Status/ or exp Employee Attitudes/ or exp EMPLOYER ATTITUDES/ or exp Management Personnel/ or exp Employee Benefits/ or exp Personnel/ or exp Health Personnel/ or exp Nurses/ or exp Medical Personnel/ or (worksite or workplace or work or employee or worker or employer or working).mp

Database: CINAHL (Ovid) 538 results

exp INFLUENZA A VIRUS/ or exp INFLUENZA, AVIAN/ or exp INFLUENZA/ or exp
INFLUENZA A VIRUS, H5N1 SUBTYPE/ or (influenza or flu).mp
AND
exp Vaccines/ or exp INFLUENZA VACCINE/ or exp Immunization/ or (immuniz$ or vaccin$ or inoculat$ or jab or jabs).mp
AND
exp “MEDICAL SOCIAL WORKER SERVICE (SABA CCC)”/ or exp work/ or exp RESCUE WORK/ or exp WORK ENVIRONMENT/ or exp “QUALITY OF WORKING LIFE”/ or exp
MOTHERS, WORKING/ or exp WOMEN, WORKING/ or exp EMPLOYEE INCENTIVE PROGRAMS/ or exp EMPLOYEE ATTITUDES/ or exp EMPLOYEE ASSISTANCE PROGRAMS/ or exp EMPLOYEE ORIENTATION/ or exp EMPLOYMENT/ or exp HEALTH PERSONNEL AS PATIENTS/ or exp PERSONNEL, HEALTH FACILITY/ or exp HEALTH PERSONNEL, INFECTED/ or exp ALLIED HEALTH PERSONNEL/ or exp HEALTH PERSONNEL, UNLICENSED/ or exp HEALTH PERSONNEL/ or exp HEALTH PERSONNEL, MINORITY/ or exp LABORATORY PERSONNEL/ or exp NURSING HOME PERSONNEL/ or (worksite or workplace or work or employee or worker or employer or working).mp

Database: Web of Science 496 results

TS=(influenza or flu) or TI=(influenza or flu)
AND
TS=(immuniz* OR vaccin* OR inoculat* OR jab OR jabs) or TI=(immuniz* OR vaccin* OR inoculat* OR jab OR jabs)
AND
TS=(worksite or workplace or work or employee or worker or employer or working)
or TI=(worksite or workplace or work or employee or worker or employer or working)
(DocType=All document types; Language=English; Databases=SCI-EXPANDED, SSCI; Timespan=1980-2007 )

Database: Science Direct 224 results

TITLE-ABSTR-KEY((worksite or workplace or work or employee or worker or employer or working) AND (immuniz* OR vaccin* OR inoculat* OR jab OR jabs) AND (influenza or flu))

Database: Embase 1409 results

‘influenza’/exp OR ‘Influenza virus’/exp OR ‘influenza vaccine’/exp or influenza or flu
AND
‘immunization’/exp OR ‘preventive health service’/exp OR ‘influenza vaccination’/exp
OR ‘virus vaccine’/exp OR ‘vaccination’/exp OR ‘vaccine’/exp OR ‘influenza
vaccine’/exp OR ‘inoculation’/exp or immuniz* OR vaccin* OR inoculat* OR jab OR jabs
AND
‘workplace’/exp OR ‘work’/exp OR ‘worker’/exp OR ‘aged worker’/exp OR ‘health care personnel’/exp OR ’employee’/exp OR ’employer’/exp OR ’employment’/exp or worksite or workplace or work or employee or worker or employer or working

Database: CSA 33 results

influenza or flu
and
immuniz* OR vaccin* OR inoculat* OR jab OR jabs
and
worksite or workplace or work or employee or worker or employer or working

Database: Proquest 152 results

influenza or flu
and
immuniz* OR vaccin* OR inoculat* OR jab OR jabs
and
worksite or workplace or work or employee or worker or employer or working

Database: Cochrane 168 results

same as Medline

Database: EconLit 7 results

(worksite or workplace or work or employee or worker or employer or working) AND
(immuniz* OR vaccin* OR inoculat* OR jab OR jabs) AND (

CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.