Worksite: Seasonal Influenza Vaccinations Using Interventions with On-Site, Free, Actively Promoted Vaccinations – Healthcare Workers

The CPSTF finding is based on evidence from a systematic review of 45 studies (search period through March 2008). The review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to worksite health promotion.

On-site, free, and actively promoted influenza vaccination interventions provide access to vaccinations for workers at the healthcare facility in which recipients normally work and at no cost to the workers. They announce vaccination availability through formal worksite announcements, such as in newsletters, e-mails, or paycheck inserts. By providing the vaccination at the worksite, employers reduce the temporal, geographic, and financial barriers that can prevent a worker from getting vaccinated.

Forty-five studies qualified for the review and examined changes in vaccination coverage, changes in influenza cases, or worker productivity.

• Change in vaccination coverage: median increase of 21.0 percentage points (interquartile interval: 11 to 34 percentage points; 41 studies)
• Change in influenza cases:
  • Among patients: median relative decrease of 11.3% (3 studies)
  • Nosocomial infections (acquired during visits to hospitals or other healthcare settings): median relative decrease of 78.0% (4 studies)
• Change in worker productivity was not reported in the qualifying studies.

Three studies were included in the economic review, one each from the U.S., Canada, and U.K. The small body of evidence indicates cost-savings but a firm conclusion cannot be reached. Monetary values are reported in 2007 U.S dollars.

• The U.S study indicated substantial savings for a hospital where nosocomial influenza infections declined from six to one following the campaign. In this study, the cost to treat one infection was estimated at $7,000. Net benefit could not be calculated because the cost of intervention was not reported.
• A net benefit of $58 to $65 per vaccinated employee was reported in a study conducted in a Canadian hospital. Benefits were based on productivity gains alone and did not consider nosocomial infections.
• The U.K study reported a cost of $692 per life year saved for a program that vaccinated staff responsible for the care of high-risk patients. The program was cost-saving when the estimate included averted work absences due to influenza.

Results from the review are applicable to workers in medium and large hospitals and long-term care facilities, including nurses and physicians.

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.

• All 45 studies evaluated interventions with free, on-site, actively promoted influenza vaccinations alone and when combined with additional interventions including provision of information, efforts to enhance access, activities to change attitudes and norms, and policy changes.
• Studies evaluated interventions conducted in medium and large hospitals, and in long-term care facilities.
• Studies were conducted mostly in the United States, Europe, and Canada; however, the body of evidence included studies from Singapore, Brazil, South Korea, and Australia.

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 — Effectiveness Review
Contains evidence from the following reviews: on-site, free, actively promoted vaccinations, and actively promoted, off-site vaccinations for healthcare workers

Economic Review

Summary Evidence Table – Economic Review

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.

Economic Review

Boersma BLPN, Rhames T, Keegan JM. Additional cost savings of an effective employee influenza program on prevention of nosocomial influenza. American Journal of Infection Control 1999; 27(2):177-8.

Burls A, Jordan R, Barton P, Olowokure B, Wake B, Albon E et al. Vaccinating healthcare workers against influenza to protect the vulnerable is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006; 24(19):4212-21.

Yassi A, Kettner J, Hammond G, Cheang M, McGill M. Effectiveness and cost-benefit of an influenza vaccination program for health care workers. Canadian Journal of Infectious Diseases 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 (

Implementation barriers identified in the broader literature include the following:

• Tight schedules for healthcare workers
• Distrust of the vaccine/medical industry
• Weekend and night-shift workers may have reduced exposure to programs
• Delay and uncertainty about the delivery of the vaccine
• Staff turnover, diversion of leadership attention, or lack of leadership involvement reduces financial and staff resources to implement new strategies
• Fear of needles

Barriers suggested by members of the review team include the following:

• Language barriers
• Mandatory programs can result in law suits
• Less flexible schedules for lower-income workers
• Prioritizing some groups over others can deter the non-prioritized groups

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of people who get the flu vaccine every year — IID‑09