Worksite: Seasonal Influenza Vaccinations Using Interventions with On-Site, Reduced Cost, Actively Promoted Vaccinations non-Healthcare Workers

The CPSTF finding is based on evidence from a systematic review of 5 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 vaccination interventions principally attempt to enhance access to the vaccine for workers and attempt to address many of the identified barriers to vaccine uptake. 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.

Five studies with six total study arms (intervention comparisons) qualified for the review and examined changes in vaccination coverage or worker productivity.

• Evaluated interventions showed median increases in vaccination coverage of:
  • 21 percentage points (2 study arms with comparison groups)
  • 38 percentage points (4 studies with no comparison group)

One study from the U.S. provided economic information for influenza vaccination programs in non-healthcare worksites. Conclusions cannot be made from this small and incomplete body of evidence. Monetary values are reported in 2007 U.S dollars.

• The cost of the vaccination program was $31.95 per person, and did not include the promotional campaign cost.
• The economic net benefit per person was $129 $53 in averted productivity losses due to work absences, and $76 in averted healthcare cost due to influenza.

Results from the review are applicable to workers in medium and large worksites.

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 non-healthcare workers: on-site, reduced cost, actively promoted vaccinations; and actively promoted off-site vaccinations.

The primary questions that remain unanswered from this review relate to cost savings and the overall effectiveness of interventions with additional components like mobile carts or incentives. To address these issues and further the knowledge of the field of worksite influenza vaccination interventions, researchers must conduct rigorous, multi-year studies with concurrent comparison worksites that evaluate on-site, off-site, and other intervention approaches. Additionally, researchers should investigate the following:

• How might the successes in increasing influenza vaccination coverage in the body of evidence for healthcare workers inform efforts in non-healthcare worksites?
• What specific barriers, besides access, should implementers address with their interventions?
• What might be the cost of presenteeism associated with influenza in the worksite, including, for example, the cost of injuries due to reduced alertness, the cost of reduced morale, and the cost of spreading infection to other workers?

• Studies evaluated interventions with reduced cost, 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 large worksites (more than 500 workers).
• Most studies were conducted in the United States, and one study was conducted in the Philippines.

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

Economic Review

Summary Evidence Table – Economic Review

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

Ausseil F. Immunization against influenza among working adults: the Philippines experience. Vaccine 1999;17 Suppl 1:S59-S62.

Dille JH. A worksite influenza immunization program. Impact on lost work days, health care utilization, and health care spending. AAOHN J 1999;47(7):301-9.

Higgins S, Walls E, Fisher A, Smith D, Humphries T. The establishment and validation of the mobile immunization team concept at a clinic level. Military Medicine 1991;156:53-5.

Janes GR, Franks AL, Stange P, Koonin LM. Worksite influenza vaccination programs: Do they reach high risk employees? (unpublished manuscript)

Strunk C. Innovative workplace influenza program: boosting employee immunization rates. AAOHN J 2005;53(10):432-7.

Economic Review

Dille JH. A worksite influenza immunization program. Impact on lost work days, health care utilization, and health care spending. Journal of the American Association of Occupational Health Nurses 1999;47(7):301-9.

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:

• Language differences
• Lack of adequate knowledge about vaccine or influenza
• Distrust of the vaccine/medical industry

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

• Less flexible schedules for lower-income workers
• Upfront costs of buying a vaccine for employer
• Employers’ perceived or actual liability

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