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Educational intervention for achieving improvements in the vaccination coverage of meningitis C in primary care
v a c u n a s . 2 0 1 9;2 0(1):25–33
Vacunas www.elsevier.es/vac
Special article
Educational intervention for achieving improvements in the vaccination coverage of meningitis C in primary care夽 M. Monreal Pérez a,∗ , M.A. Beltrán Viciano b a b
Centro de Salud Fernando El Católico, Departamento de Salud de Castellón, Castellón, Spain Unidad de Alcohología (UA) Valencia-Trinitat, Departamento de Salud de la Fe, Valencia, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Introduction: This study aims to show the importance of educational interventions in increas-
Received 22 February 2018
ing vaccination coverage. It consists of giving information about the disease of meningitis
Accepted 27 September 2018
and the efficacy of the meningitis C vaccine, as well as to observe any reactions. The objective is to verify that the vaccination rate and its registration increase after the intervention. Methodology: The study was carried out in two stages. The first stage corresponded to a
Keywords:
retrospective observational study, and the second stage was completed with a pre-post
Vaccination coverage
intervention study. The study was conducted on 351 young adults of 20 years of age, from
Meningitis C vaccine
an urban health centre in Castellón, Spain.
Educational intervention
Results: There was a 49% increase in vaccination rate after the intervention (95% CI; 43.35–54.09), with an increase in the registration of vaccination of 40.43% (95% CI; 25.33–55.52). The number needed to treat (NNT) is determined by defining it as number of interventions necessary to achieve one vaccination; obtaining a result of 3. Conclusions: The vaccination rate and its registration increased significantly after the impact of an educational intervention for young adults, with nursing staff as key personnel. The variable that was shown to have a significant relationship for the population studied was immigration. ˜ S.L.U. © 2019 Published by Elsevier Espana,
DOI of original article: https://doi.org/10.1016/j.vacun.2018.09.006. Please cite this article as: Monreal Pérez M, Beltrán Viciano MA. Intervención educativa para el logro de mejoras en la cobertura vacunal de meningitis C en atención primaria. Vacunas. 2019;20:25–33. ∗ Corresponding author. E-mail address: [email protected] (M. Monreal Pérez). https://doi.org/10.1016/j.vacune.2018.09.004 ˜ S.L.U. 2445-1460/© 2019 Published by Elsevier Espana, 夽
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Intervención educativa para el logro de mejoras en la cobertura vacunal de meningitis C en atención primaria r e s u m e n Palabras clave:
Introducción: El presente estudio pretende mostrar la importancia de las intervenciones
Cobertura vacunal
educativas a la hora de aumentar las coberturas vacunales. Consiste en dar información
Vacuna meningitis C
sobre la enfermedad meningocócica, la eficacia de la vacuna de la meningitis C y observar las
Intervención educativa
reacciones. El objetivo es comprobar que la tasa de vacunación y su registro se incrementan tras la intervención realizada. Metodología: Es un estudio realizado en 2 etapas. La primera etapa corresponde a un estudio observacional retrospectivo y la segunda se completa con un estudio prepostintervención. ˜ Dicho estudio se realizó sobre 351 adolescentes de 20 anos de edad, en un centro de salud ˜ urbano perteneciente al departamento de Castellón, Espana. Resultados: Tras la intervención se obtuvo un incremento en la tasa de vacunación del 49% (IC 95%: 43,35-54,09), con un incremento en el registro de la vacunación de un 40,43% (IC 95%: 25,33-55,52). La cobertura vacunal media en el centro de salud, para las 3 dosis de la vacunación sistemática, durante 2007 fue superior al 80%. Se determinó el número necesario a tratar definiéndolo como número de intervenciones necesarias para conseguir la vacunación de uno, obteniendo un resultado de 3. Conclusiones: La tasa de vacunación y su registro se incrementan de forma significativa tras el impacto de una intervención educativa para adolescentes, con el personal de enfermería como personal clave. La cobertura vacunal sistemática del centro de salud estudiado es buena. La variable que ha demostrado tener una relación significativa para nuestra población en estudio es la inmigración. ˜ S.L.U. © 2019 Publicado por Elsevier Espana,
Introduction Epidemiology of meningococcal disease The incidence of meningococcal disease declined in Spain after vaccination with the polysaccharide vaccine in 1997–1999. In the 1999–2000 season, an increase of the disease was observed in Spain, and in particular in the Autonomous Region of Valencia, with 134 cases declared.1 This increase was due to susceptible individuals who were left out of the immunisation campaign: individuals aged over 20, born in 1997 and children who did not reach the minimum age for vaccination. Vaccinated individuals who were between 18-months-old and 4-years-old during the vaccination campaign with the polysaccharide vaccine, which due to its characteristics did not grant long-lasting immunity, also fell ill. MenC conjugate vaccines generate indirect group protection (demonstrated due to the reduction in the rate of attack of non-vaccinated individuals) by reducing the rate of nasopharyngeal carriers of serogroup C meningococcal disease. The latter rate is up to four times higher in adolescents and young adults than in children, which is why vaccine rescue in older children strengthens the herd immunity due to the decrease in the number of nasopharyngeal carriers, mainly in adolescents.2,3 As regards the vaccination schemes against serogroup C meningococcal disease, it must be borne in mind that, despite the success achieved with the MenC conjugate
vaccine, epidemiological surveillance studies conducted in Spain4–6 have revealed some weak points of the vaccination strategy, which makes it necessary to reconsider some new childhood vaccination guidelines, seeking to optimise the schedule. The main points to resolve are the progressive loss of antibodies after the vaccination of infants in the first year of life, the decline in vaccine coverage in children from the age of 12 months with the consequent increase in the susceptible population, the emergence of cases in vaccinated individuals (vaccine failures) and the increase in cases of disease in adolescents and young adults, which remain a particularly susceptible population, according to the MenC conjugate working group, 2012.7 The Ministry of Health, Social Services and Equality, in its ruling dated 24 July 2013, modified the vaccination guidelines of several vaccines. Subsequently, the Interterritorial Council of the Spanish National Health System, in the plenary session of 21 March 2013, completed the common schedule agreement of childhood vaccination of the National Health System, reporting favourably on the vaccination guidelines against serogroup C meningococcal disease. The MenC conjugate vaccine will therefore be administered at 4 months, 12 months and 12 years of age, instead of at 2 months, 4 months and 12 months.
Following of health recommendations by the general population Among the main causes of lack of adherence to treatments is forgetting to take them, insufficient information on their
v a c u n a s . 2 0 1 9;2 0(1):25–33
efficacy or fear of their side effects. In any case, the determinants of this lack of adherence are complex, and in many cases difficult to specify, as it is not rare for psychological, social, cultural or economic factors, among others, to also have an influence. As far as vaccines are concerned, the problem of lack of adherence is similar to the rest of treatments and medical recommendations. In the paediatric population, the following of vaccination programmes is acceptable in most developed countries. However, from adolescence, the following of existing programmes decreases.8
Material and methods Hypothesis An educational intervention, performed by nursing personnel, is effective to increase the vaccination rate and its registration in adolescents.
Objectives General To check that the vaccination rate and the registration increase after the impact of an educational intervention for adolescents, carried out by nursing personnel in the Centro de Salud Rafalafena [Rafalafena Health Centre], Castellón de la Plana, Spain.
Specifics 1. To evaluate the vaccination coverage with three doses, according to the vaccination schedule, with the meningococcal C conjugate vaccine, at the Rafalafena Health Centre. 2. To determine the sociodemographic and clinical variables associated with the compliance of the meningococcal C conjugate vaccine. 3. To determine the response of adolescents in light of an educational intervention at the Rafalafena Health Centre. 4. To recognise the importance of nursing personnel to increase the coverage of meningitis C at the Rafalafena Health Centre. 5. To determine the number of educational interventions necessary to achieve recruitment for the vaccination of one individual.
Study design The study was carried out in two stages. The first corresponded to a retrospective observational study, to determine the vaccination rate of our population. The second stage involved the completion of a pre-post intervention study.
Variables Data were collected from vaccination procedures in 2006 (previous year), 2007 and 2008 (subsequent years) in the intervention with the MenC conjugate vaccine of 20-year-old patients at the Rafalafena Health Centre. This is the age that the intervention was aimed at.
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The following clinical variables were obtained from each patient at the Rafalafena Health Centre: vaccinated or not, both before the intervention and after it; and if the individual had received the information by post or by telephone. In addition, the following sociodemographic variables were collected: gender (male or female), nationality (immigrant or non-immigrant) and year of birth.
Data collection procedure In order to obtain the list of patients born in 1987 and belonging to the health centre, a consultation was performed in the database of the Sistema de Información Poblacional [Population Information System] (SIP). To complete the data collection, the Sistemas de Información Vacunal [Vaccination Information Systems] (SIV), the information system of the Autonomous Region of Valencia from which data on the population vaccination coverage are extracted, and the registry where all vaccines administered are declared, were referred to. ® A database was designed in Microsoft Access to manage all the data. The statistical programme Epidat v.3.1 was used for the data processing. The participants’ identifying data were not used in any phases of the study. In a first phase, to obtain data from the different variables, the SIP number was used. Once all the necessary data were obtained, the SIP of each patient was replaced with a code, so that it was not possible to identify participants in the different analyses of the data.
Participants Patients from a total of 13 specialist medical consultations in Family and Community Medicine and 13 nursing consultations of the above-mentioned health centre participated in the study. We chose the cohort of individuals born in 1987 because, after the strategies performed from November 2002 by the Regional Ministry of Health of the Autonomous Region of Valencia, which consisted of offering the vaccination with the meningitis C conjugate vaccine to the Valencian population under the age of 20, it was established that there were individuals who had not been vaccinated. This vaccination strategy was carried out in: 1. Health centres, by means of posters. 2. Visits to secondary schools, making use of the school vaccination programme, with administration of the routine hepatitis B vaccine to 12-year-old children (1st year of compulsory secondary education). 3. Visits to secondary schools, making use of the routine vaccination of diphtheria-tetanus of 13–14 year-old children (2nd year of compulsory secondary education). Our study cohort did not benefit from part of this strategy as, in 2002, when public health launched its vaccination proposal, they were already 15-years-old (3rd year of compulsory secondary education) and in this year interventions with routine vaccinations were not performed. They only had the opportunity to get themselves vaccinated by means of the information provided by posters distributed in health centres.
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This cohort from 1987 was also chosen because it was the last opportunity to be vaccinated as in 2007, the year of the intervention, they turned 20 and, according to the summary of product characteristics, this was the maximum permitted age for this vaccination.
Table 1 – Subjects under study before the intervention. Before the intervention N = 351
Vaccinated
Total Males N = 177 Females N = 174
14 (4.0%) 7 (4.0%) 7 (4.0%)
Not vaccinated 337 (96.0%) 170 (96.0%) 167 (96.0%)
The following were included in the study - All individuals born in 1987 belonging to the Rafalafena Health Centre. - Those who were not vaccinated with the meningococcal C conjugate vaccine. - Those who had a previous dose of the plain A + C polysaccharide vaccine.
- Individuals who had had an anaphylactic reaction to any previous dose of the vaccine. - Those who had shown hypersensitivity to any component of the vaccine. - Individuals who cannot read letters or understand telephone calls (physical disability, severe psychiatric disorder). - Pregnant and breastfeeding women. - Patients on systemic immunosuppressive therapy.
on the letter. The call was made by the health centre nursing personnel from the paediatric nursing clinic. The method used for the selection of letter or telephone call was carried out according to simple random sampling, thereby ensuring that each member of the population had the same probability of being selected as a subject. Patients who accepted came in the established time slots or were given an appointment in the paediatric nursing clinic where the vaccine was administered and it was registered in the Registro Nominal de Vacunas [Nominal Vaccination Registry] (RNV). They were informed of the intervention that was being carried out and of the purpose of it, inviting them to read and sign the consent for the research. The intervention was performed at the paediatric nursing clinic because the nurse was also head of vaccination at the centre. They were administered ® the Menjugate vaccine.
Vaccination of the adolescent is delayed
Ethical aspects
- If the patient has just received a meningococcal polysaccharide vaccine, a minimum interval of six months must be maintained in order to be able to administer the meningococcal C conjugate vaccine. - In acute disease, until the individual has recovered (due to the differential diagnosis in the event of the onset of a possible adverse reaction).
This study was performed following the recommendations and ethical principles established in the 1964 Declaration of Helsinki, and subsequent updates, in relation to medical research carried out with the participation of human subjects. The relevant authorisation was requested from the Chief Executive Officer of the Rafalafena Health Centre for the conduct of the intervention on participants, as well as the subsequent use of data. Authorisation was also requested to participate in the research, after ensuring that the patient had understood the information that he/she was given about the study objectives, benefits, discomforts and possible risks of the informed consent. In order to preserve the anonymity of the sample, patients were given a code when included in the study, so that no other identifying data concerning them appeared in any phase of the study.
The following were excluded from the study
Sample size It was decided to perform a pilot study for the calculation of the sample, taking for this 30 individuals who complied with the inclusion/exclusion criteria. Epidat v.3.1 was used for the calculation of the sample. According to the data, a 30% improvement in the vaccination rate was observed, which required 316 individuals for a 95% confidence interval, and a precision of 5%. In addition, if a 10% loss occurred, we would need 351 patients, so we included 100% of our sample. A 10% sample loss of subjects due to change of address or change of telephone number was presumed during the study period.
Results
Procedure
Characteristics of the study population
The educational intervention was performed during the first three months of 2007: one group was sent an educational letter aimed at patients by post (as they were of legal age), in DIN A4 format, in which the significance of meningococcal disease, as well as the efficacy and safety of vaccination against disease, was highlighted, indicating the contact telephone numbers in case of queries, as well as the time slots during which they could come to be vaccinated. This letter was drafted following the recommendations of the Centers for Disease Control and Prevention and the Regional Ministry of Health and Consumption of the Autonomous Region of Valencia. Another group of participants were called by telephone, offering them the same explanation as that which appeared
As can be observed in Table 1, 351 individuals were recruited initially. Of these, 177 were male and 174 female. Of the total size of the sample (N = 351), we found that 14 participants were immigrants (7 males and 7 females). The age of the subjects was 19–20 as they were all born in 1987. Prior to the educational intervention, a total of 14 vaccinated and registered individuals (7 males and 7 females) were found out of 351 susceptible subjects, with 337 non-vaccinated individuals, of whom 170 were males and 167 females. Of these 337, two individuals were lost to follow-up because personal data to contact them was not available. A sample of 335 therefore remained (Fig. 1).
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Table 3 – Codifications of categorical variables. N = 351
• Loss of 2 individuals due to lack of contact details
Parameter coding Immigrants
N = 349
Recruitment
• Less than 14 subjects who were already vaccinated and registered
N = 335
• Final sample
Fig. 1 – Summary of the evolution of the sample. Prepared by the authors.
Vaccination rate and registration after educational intervention for adolescents After the intervention, as shown in Table 2, from a sample of 335 participants, 171 (52.7%) got vaccinated and 164 (46.7%) did not get vaccinated. With these data, an increase in the vaccination rate of 49% was established (95% CI: 43.35–54.09). Of those vaccinated, 52.6% were males and 47.4% females, compared to 47.5% of males and 52.4% of females who did not get vaccinated. Regarding the educational intervention, it was revealed that 197 (58.8%) participants were contacted by letter, achieving the vaccination of 108 compared to 89 participants who did not get vaccinated, while 138 (41.2%) participants were contacted by telephone call, resulting in 63 adolescents getting vaccinated compared to 75 who did not get vaccinated (Table 1). No statistically significant differences were observed in the efficacy of the interventions. The total number of the sample was 351 individuals. Of these, two were lost to follow-up due to lack of contact details. Of the total of 349, 14 individuals who were already vaccinated and registered were identified. A total of 335 individuals who were not vaccinated or registered therefore remained. During the intervention, it was found that, of these 335, there were 19 adolescents who appeared as not vaccinated in the nominal registry, but when bringing the immunisation record, it was revealed that they were vaccinated against meningitis C, but they were not registered. As at this point of the study we were referring exclusively to the registration of the vaccination, an increase of 19 individuals was observed in the RNV.
Gender
1 0 1 0 1 0
Independent variable label Non-immigrant Immigrant Recruitment by letter Recruitment by telephone Male Female
An estimation for a proportion was performed, with a 95% confidence interval. After the intervention, an increase in the vaccination registration of 40.43% (N = 19) was seen, with a 95% CI: 25.33–55.52; p = 0.000.
Factors related to the compliance of the meningococcal vaccine By having a dichotomous dependent variable on which it was wished to evaluate the association or connection with other independent variables such as gender, immigrant or non-immigrant and recruited either by letter or by telephone contact, the procedure to be performed was a multivariate binary logistic regression. Table 3 shows the codification used in the independent variables. In this study, the variables selected were: gender, immigrants and method of recruitment (either by letter or by telephone contact). Table 4 displays the estimated parameter (B), its standard error (ET) and its statistical significance with the Wald test (statistic that follows a Chi-square law with a degree of freedom), and the OR calculation (Exp(B)). In this first block, only the constant appears in the regression equation, with the variables having remained outside. The proportion of variability of the “Compliance of the vaccine against meningococcal disease” explained by the following models which appear in Tables 6a–6c is not very good, as we can see a discrete Cox and Snell R2 of 0.027, which indicates that only 2.7% of the variation of the dependent variable, complying or not complying with the vaccination against meningococcal disease is explained by the variables included in the model (Table 5). By performing the correction with Nagelkerke’s R2 , we observed a result which was also discrete of 0.036 (3.6%). Therefore, there continued to be a significant percentage of “influence” on the fact of complying with the meningococcal vaccine which did not depend on the variables analysed. Finally, in Tables 6a–6c variables which would be left in the equation, their regression coefficients with their corresponding standard errors, the Wald statistical value to evaluate the
Table 2 – Informative interventions in the study population. After the intervention N = 335 2 (0.6%) losses
Not vaccinated 164 (46.7%) Males
Letter 197 (58.8%) Telephone 138 (41.2%)
78 (47.5%) 47 (60.3%) 31 (39.7%)
Vaccinated 171 (52.7%) Females
Males
86 (52.4%) 42 (48.8%) 44 (51.2%)
90 (52.6%) 51(56.7%) 39(43.3%)
Females 81 (47.4%) 57 (70.4%) 24 (29.6%)
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Table 4 – Equation variables.
Step 0
Constant
B
ET
Wald
df
Sig.
Lower 0.048
Upper 0.109
Lower 0.192
Upper 1
Lower 0.662
Exp(B) OR Upper 1.049
Table 5 – Summary of the models. Step
−2 log likelihood
Cox and Snell’s R2
Nagelkerke’s R2
1
453.738 (a)
0.027
0.036
Table 6a – Equation variables.
Step 1 (a)
IMMIGRANTS (1) Constant
B Low.
ET Upp.
Wald Low.
df Upp.
Sig. p Low.
Exp(B) Upp.
95% CI for EXP(B) Low.
Upp.
0.971 0.788
0.333 0.311
8.485 6.411
1 1
0.004 0.011
2.640 0.455
1.374
5.073
Log-likelihood of the model
Change in −2 log-likelihood
df
Sig. of change
−231.415
9.093
1
0.003
Table 6b – Model if the term is eliminated. Variable Step 1
Immigrants
Table 6c – Variables not in the equation.
Step 1
Variables
GENDER (1) RECRUITMENT (1)
Overall statistics
null hypothesis (Pi = 0), the associated statistical significance and the OR value (Exp(B)) with its confidence intervals appear and continue. As can be seen, only the “Immigrant” variable appears, as the statistical level of significance of the Wald test is 0.004, which indicates that it is a useful parameter for the model. The rest of the gender and recruitment variables were rejected because their level of significance was greater than 0.05. Therefore, we cannot reach any conclusion with these independent variables (Tables 6a–6c).
Determination of the number of educational interventions which have to be performed for the recruitment of one individual The number needed to treat (NNT) was calculated. The NNT was determined, defining it as the number of interventions necessary to achieve the vaccination of one person. The proportion of patients vaccinated before the intervention was 0.04, and the proportion of subjects after the intervention was 0.53. It was therefore estimated that we needed to perform an educational programme with three individuals in order to manage to recruit one.
Discussion After a search performed in PubMed, with the search strategy “Spain AND meningococcal AND vaccine”, this study is the
Score
df
Sig.
0.523 1.714 2.274
1 1 2
0.469 0.190 0.321
largest of this type of those carried out in Spain during this period of time (Table 7). Regarding the characteristics of participants in the study, males predominate, although in a percentage which is identical to the predominance of this gender in the population of the city of Castellón, in the same age range, according to official data of the Spanish National Statistics Institute (INE) in 2007. As in other studies performed with other vaccines,15–21 the conduct of a direct information activity is revealed as an effective method to increase vaccine coverage, much more so than indirect information through leaflets, posters, etc. As we can see in the study, active recruitment offers a 49% increase in vaccination, with a 95% CI and 40.43% increase in vaccination registration, with a 95% CI: 25.33–55.52. Szilagyi20 performed direct educational interventions (letter, telephone call) on a marginal adolescent population to increase vaccine coverage against serogroup C meningococcal disease, pertussis and human papilloma virus that obtained certain improvements (21% by letter, 17% by telephone and 13% control) with a low economic cost. The results obtained are modest in comparison with those of our study, although it also has to be borne in mind that, in this intervention, the socioeconomic status was not considered as a study variable, nor was it acted upon taking the study population only as a marginal population, meaning that it cannot be concluded that the difference in the results of both studies is the cause of being a population with low economic income. Chung,20 in his work on an adolescent population in a rural environment, in Duplin County (North Carolina), by means of
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Table 7 – Different studies published up to 2017. Author
Population
Instrument
Type of vaccine
Country
˜ Ibanez-Jimenez A, et al. (2007)9 Kolasa MS, et al. (2009)10 Cardemil CV, et al. (2016)11 Swallow W, Roberts JC (2016)12
24–30 years
Postal reminder
Tetanus-diphtheria
Spain
19 months
Letter and telephone
Routine vaccination
USA
19–35 months 13–17 years A secondary school
Registration of vaccines Vaccination schedule
USA
Cadena J, et al. (2016)13
Health workers
Influenza
Texas
Bay SL, Crawford DJ (2016)14
19 months Children with respiratory problems
Audit of information system suppliers 2 submissions of letters + email + telephone call from school nurse to parents Telephone message Message on screen e-Mail Letter and telephone
Routine vaccines
USA
direct interventions (post, telephone) obtained improvement compared to other comparable counties, in the vaccine coverage against meningitis C (of 34.6% prior to the intervention to 49.4% post-intervention). In his article they mention having a web-based vaccine registry (North Carolina Immunization Registry [NCIR]) and offering economic incentives to participating professionals for completion and economic evaluation of the interventions. Van der Meer et al. conclude in their study that by using an active method (personal letter) and a passive method (poster), minimal results are obtained in the second.22 In view of the study results, it can be concluded that the interventions aimed at adolescents related to vaccination programmes must be planned actively and directly, as it is a group that attends health centres little or very little. The nurse is the key member of personnel when doing educational interventions aimed at active recruitment. In different studies23–26 reference is made to the importance of the nurse as a facilitating agent to increase vaccine coverage, whether by reminder calls, as in the case of Whelan,24 or as school nurses in the case of Bobo25 and Pudelco et al.26 The importance of the nursing team in immunisation, coordination of programmes, planning, evaluation and monitoring of vaccination coverage is highlighted. Therefore, the results of our study coincide with the study hypothesis, as without the nursing intervention in the active search and after vaccination of the adolescents, these individuals would not have been vaccinated, as the year studied was the last year permitted by the summary of product characteristics. The Community Preventive Services Task Force confirms that the role of nursing is fundamental when increasing vaccine coverage. In 2015, the World Health Organization (WHO) published a technical guideline for the member states, with the support of the WHO Regional Office for Europe, to empower and increase the contribution of nurses to achieve the Health 2020 goals.27 In this guideline, nurses are proposed as key personnel for the comprehensive care of patients. Vaccination registration is an important topic as the nominal registry systems (Meningitis C Prevention Plan in the
USA
Autonomous Region of Valencia, 2002)28 are a fundamental element to perform monitoring of vaccine coverage, therefore being able to recruit at-risk population groups which have not been subject to recommended vaccinations. In the Autonomous Region of Valencia, the vaccination campaign against serogroup C meningococcal disease was implemented in 2000, but it was not until 2004 that it started to be used comprehensively, coinciding with the implementation of the Administrative Information System (SIA). We agree with the 2011 recommendations from the CDC29 in which the importance of registering vaccinations and the need for the information to be reflected in the patient’s medical history is emphasised. The usefulness of the registration for not giving extra doses, the requirement to register any adverse event after vaccination and the importance of giving parents or guardians a registration card, and informing them of the importance of this document, is also pointed out. A review performed by the Community Preventive Services Task Force in which 240 articles or summaries addressing this topic were included,30 makes it possible to confirm that the information systems support interventions effectively with regard to increasing the vaccination rates and their registration. After the intervention carried out at Rafalafena, a 49% increase in vaccine coverage was reached, thanks partly to having information systems available. As in the articles gathered by the Task Community, our study enabled it to be concluded that these information systems are useful for: 1. Determining the vaccination status of the population to facilitate the taking of clinical, epidemiological or management decisions. 2. Orientating the responses of public health to outbreaks of vaccine-preventable diseases. 3. Evaluating the coverage of the vaccination. 4. Facilitating the management and evaluation of vaccination programmes. No differences in response between males and females were found. However, a greater response was determined in the immigrant population, although this piece of information
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must be interpreted with caution as it was a very small and non-representative sample. No significant differences were found either between sending the message by letter or by telephone call. Like all epidemiological studies, this investigation has limitations. In the study conducted, the total number of immigrants of the sample is not representative of the general population, as all of them respond to recruitment performed for the study and, therefore, we cannot include it as a factor influencing vaccination. We need to carry out studies comparing the recruitment performed of immigrants against non-immigrant subjects. We assume that the study would have been more enriching if we had taken into account factors such as socio-cultural level, characteristics of the immigrant population, if alternative medicine was used and if they went to a private doctor.
Conflicts of interest The authors declare that they have no conflicts of interest.
references
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10. Kolasa MS, Lutz JP, Cofsky A, Jones YT. Provider chart audits and outreach to parents: impact in improving childhood immunization coverage and immunization information system completeness. J Public Health Manag Pract. 2009;15:459–63. 11. Cardemil CV, Cullen KA, Harris L, Greby SM, Santibanez TA. Factors associated with provider reporting of child and adolescent vaccination history to immunization information systems: results from the National Immunization Survey, 2006–2012. J Public Health Manag Pract. 2016;22: 245–54. 12. Swallow W, Roberts JC. An evidence-based project demonstrating increased school immunization compliance following a school nurse-initiated vaccine compliance strategy. J Sch Nurs. 2016;32:385–9. 13. Cadena J, Prigmore T, Bowling J, Ayala BA, Kirkman L, Parekh A, et al. Improving influenza vaccination of healthcare workers by means of quality improvement tools. Infect Control Hosp Epidemiol. 2016;32:616–8. 14. Bay SL, Crawford DJ. Using technology to affect influenza vaccine coverage among children with chronic respiratory conditions. J Pediatr Health Care. 2016;31:155–60. 15. Centers of Disease Control and prevention. Control and Prevention of meningococcal disease and control and prevention of serogrupo C meningoccoccal disease: evaluation and management of suspected outbreaks. Recommendations of advisory Committee on Immunization Practices (ACIP). MMWR (No. RR-7). 2000:1–21. 16. Thomas RE, Russell M, Lorenzetti D. Interventions to increase influenza vaccination rates of those 60 years and older in the community. Cochrane Database Syst Rev. 2010;9. CD005188. 17. Pastor E, et al. Recaptación Activa de la 1.a y 2.a dosis de triple vírica en la Comunidad Valenciana. Utilización y rendimiento de la herramienta del Sistema de Información Vacunal (SIV). ˜ 6.◦ Congreso de la Asociación Espanola de Vacunología. Santiago de Compostela, 23 al 26 de noviembre; 2011. 18. Roca B, Herrero E, Resino E, Torres V, Penades M, Andreu C. Impact of education program on influenza vaccination rates in Spain. Am J Manag Care. 2012;18:e446–52. 19. Bernal-González PJ, Navarro-Alonso JJ, Pérez-Martín J. Computerised Vaccination register for the Murcia Region Spain, 1991–2011. Euro Surveill. 2012;17, pii:20150. 20. Szilagyi PG, Albertin C, Humiston SG, Rand CM, Schaffer S, Brill H, et al. A Randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents. Acad Pediatr. 2013;13:204–13, http://dx.doi.org/10.1016/j.acap.2013.01.002. 21. Chung RJ, Walter EB, Kemper AR, Dayton A. Keen on teen vaccines: improvement of adolescent vaccine coverage in Rural North Carolina. J Adolesc Health. 2015;56 Suppl. 5:S14–6, http://dx.doi.org/10.1016/j.jadohealth.2014.10.272. 22. Van der Meer V, Nielen MM, Drenthen AJ, van Vliet M, Assendelft WJ, Schellevis FG. Cardiometabolic prevention consultation in the Netherlands: screening uptake and detection of cardiometabolic risk factors and diseases – a pilot study. BMC Fam Pract. 2013;14:29, http://dx.doi.org/10.1186/1471-2296-14-29. 23. Kothari A. VPH vaccination: effects on cervical screening. Nurs Times. 2014;110:19–21. 24. Whelan NW, Steenbeek A, Martin-Misener R, Scott J, Smith B, D’Angelo-Scott H. Engaging parents and schools improves uptake of the human papillomavirus (HPV) vaccine: examining the role of the public health nurse. Vaccine. 2014;32:4665–71, http://dx.doi.org/10.1016/j.vaccine.2014.06.026. 25. Bobo N. Increasing inmmunization rates through the immunization neighbourhood recognizing school-located immunization programs. Nasn Sch Nurse. 2014;29: 224–8.
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26. Pudelco P, Koehler AE, Bisetto LH. Impact of vaccination in the reduction of hepatitis B in Paraná. Rev Gaucha Enferm. 2014;35:78–86. 27. Oficina Regional para Europa. European Vaccine Action Plan 2015–2020. Available from: http://www.euro.who.int/en/health-topics/diseaseprevention/vaccines-and-immunization/publications/2014/ european-vaccine-action-plan-20152020 [accessed 15.09.15]. 28. Plan de Prevención de la Meningitis C en la Comunidad Valenciana, (2002). En publicaciones.san.gva.es/publicaciones/documentos/V.14202006.pdf.
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29. Centers of Disease Control and prevention. General recommendations on immunization: recommendations of advisory committee on immunization practices (ACIP). Morb Mort Wkly Rep (MMWR). 2011:1–60. 30. Groom H, Hopkins DP, Pabst LJ, Murphy Morgan J, Patel M, Calonge N, et al. Immunization information systems to increase vaccination rates: a community guide systematic review. J Public Health Manag Pract. 2015;21:227–48, http://dx.doi.org/10.1097/PHH.0000000000000069.
Vacunas www.elsevier.es/vac
Special article
Educational intervention for achieving improvements in the vaccination coverage of meningitis C in primary care夽 M. Monreal Pérez a,∗ , M.A. Beltrán Viciano b a b
Centro de Salud Fernando El Católico, Departamento de Salud de Castellón, Castellón, Spain Unidad de Alcohología (UA) Valencia-Trinitat, Departamento de Salud de la Fe, Valencia, Spain
a r t i c l e
i n f o
a b s t r a c t
Article history:
Introduction: This study aims to show the importance of educational interventions in increas-
Received 22 February 2018
ing vaccination coverage. It consists of giving information about the disease of meningitis
Accepted 27 September 2018
and the efficacy of the meningitis C vaccine, as well as to observe any reactions. The objective is to verify that the vaccination rate and its registration increase after the intervention. Methodology: The study was carried out in two stages. The first stage corresponded to a
Keywords:
retrospective observational study, and the second stage was completed with a pre-post
Vaccination coverage
intervention study. The study was conducted on 351 young adults of 20 years of age, from
Meningitis C vaccine
an urban health centre in Castellón, Spain.
Educational intervention
Results: There was a 49% increase in vaccination rate after the intervention (95% CI; 43.35–54.09), with an increase in the registration of vaccination of 40.43% (95% CI; 25.33–55.52). The number needed to treat (NNT) is determined by defining it as number of interventions necessary to achieve one vaccination; obtaining a result of 3. Conclusions: The vaccination rate and its registration increased significantly after the impact of an educational intervention for young adults, with nursing staff as key personnel. The variable that was shown to have a significant relationship for the population studied was immigration. ˜ S.L.U. © 2019 Published by Elsevier Espana,
DOI of original article: https://doi.org/10.1016/j.vacun.2018.09.006. Please cite this article as: Monreal Pérez M, Beltrán Viciano MA. Intervención educativa para el logro de mejoras en la cobertura vacunal de meningitis C en atención primaria. Vacunas. 2019;20:25–33. ∗ Corresponding author. E-mail address: [email protected] (M. Monreal Pérez). https://doi.org/10.1016/j.vacune.2018.09.004 ˜ S.L.U. 2445-1460/© 2019 Published by Elsevier Espana, 夽
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v a c u n a s . 2 0 1 9;2 0(1):25–33
Intervención educativa para el logro de mejoras en la cobertura vacunal de meningitis C en atención primaria r e s u m e n Palabras clave:
Introducción: El presente estudio pretende mostrar la importancia de las intervenciones
Cobertura vacunal
educativas a la hora de aumentar las coberturas vacunales. Consiste en dar información
Vacuna meningitis C
sobre la enfermedad meningocócica, la eficacia de la vacuna de la meningitis C y observar las
Intervención educativa
reacciones. El objetivo es comprobar que la tasa de vacunación y su registro se incrementan tras la intervención realizada. Metodología: Es un estudio realizado en 2 etapas. La primera etapa corresponde a un estudio observacional retrospectivo y la segunda se completa con un estudio prepostintervención. ˜ Dicho estudio se realizó sobre 351 adolescentes de 20 anos de edad, en un centro de salud ˜ urbano perteneciente al departamento de Castellón, Espana. Resultados: Tras la intervención se obtuvo un incremento en la tasa de vacunación del 49% (IC 95%: 43,35-54,09), con un incremento en el registro de la vacunación de un 40,43% (IC 95%: 25,33-55,52). La cobertura vacunal media en el centro de salud, para las 3 dosis de la vacunación sistemática, durante 2007 fue superior al 80%. Se determinó el número necesario a tratar definiéndolo como número de intervenciones necesarias para conseguir la vacunación de uno, obteniendo un resultado de 3. Conclusiones: La tasa de vacunación y su registro se incrementan de forma significativa tras el impacto de una intervención educativa para adolescentes, con el personal de enfermería como personal clave. La cobertura vacunal sistemática del centro de salud estudiado es buena. La variable que ha demostrado tener una relación significativa para nuestra población en estudio es la inmigración. ˜ S.L.U. © 2019 Publicado por Elsevier Espana,
Introduction Epidemiology of meningococcal disease The incidence of meningococcal disease declined in Spain after vaccination with the polysaccharide vaccine in 1997–1999. In the 1999–2000 season, an increase of the disease was observed in Spain, and in particular in the Autonomous Region of Valencia, with 134 cases declared.1 This increase was due to susceptible individuals who were left out of the immunisation campaign: individuals aged over 20, born in 1997 and children who did not reach the minimum age for vaccination. Vaccinated individuals who were between 18-months-old and 4-years-old during the vaccination campaign with the polysaccharide vaccine, which due to its characteristics did not grant long-lasting immunity, also fell ill. MenC conjugate vaccines generate indirect group protection (demonstrated due to the reduction in the rate of attack of non-vaccinated individuals) by reducing the rate of nasopharyngeal carriers of serogroup C meningococcal disease. The latter rate is up to four times higher in adolescents and young adults than in children, which is why vaccine rescue in older children strengthens the herd immunity due to the decrease in the number of nasopharyngeal carriers, mainly in adolescents.2,3 As regards the vaccination schemes against serogroup C meningococcal disease, it must be borne in mind that, despite the success achieved with the MenC conjugate
vaccine, epidemiological surveillance studies conducted in Spain4–6 have revealed some weak points of the vaccination strategy, which makes it necessary to reconsider some new childhood vaccination guidelines, seeking to optimise the schedule. The main points to resolve are the progressive loss of antibodies after the vaccination of infants in the first year of life, the decline in vaccine coverage in children from the age of 12 months with the consequent increase in the susceptible population, the emergence of cases in vaccinated individuals (vaccine failures) and the increase in cases of disease in adolescents and young adults, which remain a particularly susceptible population, according to the MenC conjugate working group, 2012.7 The Ministry of Health, Social Services and Equality, in its ruling dated 24 July 2013, modified the vaccination guidelines of several vaccines. Subsequently, the Interterritorial Council of the Spanish National Health System, in the plenary session of 21 March 2013, completed the common schedule agreement of childhood vaccination of the National Health System, reporting favourably on the vaccination guidelines against serogroup C meningococcal disease. The MenC conjugate vaccine will therefore be administered at 4 months, 12 months and 12 years of age, instead of at 2 months, 4 months and 12 months.
Following of health recommendations by the general population Among the main causes of lack of adherence to treatments is forgetting to take them, insufficient information on their
v a c u n a s . 2 0 1 9;2 0(1):25–33
efficacy or fear of their side effects. In any case, the determinants of this lack of adherence are complex, and in many cases difficult to specify, as it is not rare for psychological, social, cultural or economic factors, among others, to also have an influence. As far as vaccines are concerned, the problem of lack of adherence is similar to the rest of treatments and medical recommendations. In the paediatric population, the following of vaccination programmes is acceptable in most developed countries. However, from adolescence, the following of existing programmes decreases.8
Material and methods Hypothesis An educational intervention, performed by nursing personnel, is effective to increase the vaccination rate and its registration in adolescents.
Objectives General To check that the vaccination rate and the registration increase after the impact of an educational intervention for adolescents, carried out by nursing personnel in the Centro de Salud Rafalafena [Rafalafena Health Centre], Castellón de la Plana, Spain.
Specifics 1. To evaluate the vaccination coverage with three doses, according to the vaccination schedule, with the meningococcal C conjugate vaccine, at the Rafalafena Health Centre. 2. To determine the sociodemographic and clinical variables associated with the compliance of the meningococcal C conjugate vaccine. 3. To determine the response of adolescents in light of an educational intervention at the Rafalafena Health Centre. 4. To recognise the importance of nursing personnel to increase the coverage of meningitis C at the Rafalafena Health Centre. 5. To determine the number of educational interventions necessary to achieve recruitment for the vaccination of one individual.
Study design The study was carried out in two stages. The first corresponded to a retrospective observational study, to determine the vaccination rate of our population. The second stage involved the completion of a pre-post intervention study.
Variables Data were collected from vaccination procedures in 2006 (previous year), 2007 and 2008 (subsequent years) in the intervention with the MenC conjugate vaccine of 20-year-old patients at the Rafalafena Health Centre. This is the age that the intervention was aimed at.
27
The following clinical variables were obtained from each patient at the Rafalafena Health Centre: vaccinated or not, both before the intervention and after it; and if the individual had received the information by post or by telephone. In addition, the following sociodemographic variables were collected: gender (male or female), nationality (immigrant or non-immigrant) and year of birth.
Data collection procedure In order to obtain the list of patients born in 1987 and belonging to the health centre, a consultation was performed in the database of the Sistema de Información Poblacional [Population Information System] (SIP). To complete the data collection, the Sistemas de Información Vacunal [Vaccination Information Systems] (SIV), the information system of the Autonomous Region of Valencia from which data on the population vaccination coverage are extracted, and the registry where all vaccines administered are declared, were referred to. ® A database was designed in Microsoft Access to manage all the data. The statistical programme Epidat v.3.1 was used for the data processing. The participants’ identifying data were not used in any phases of the study. In a first phase, to obtain data from the different variables, the SIP number was used. Once all the necessary data were obtained, the SIP of each patient was replaced with a code, so that it was not possible to identify participants in the different analyses of the data.
Participants Patients from a total of 13 specialist medical consultations in Family and Community Medicine and 13 nursing consultations of the above-mentioned health centre participated in the study. We chose the cohort of individuals born in 1987 because, after the strategies performed from November 2002 by the Regional Ministry of Health of the Autonomous Region of Valencia, which consisted of offering the vaccination with the meningitis C conjugate vaccine to the Valencian population under the age of 20, it was established that there were individuals who had not been vaccinated. This vaccination strategy was carried out in: 1. Health centres, by means of posters. 2. Visits to secondary schools, making use of the school vaccination programme, with administration of the routine hepatitis B vaccine to 12-year-old children (1st year of compulsory secondary education). 3. Visits to secondary schools, making use of the routine vaccination of diphtheria-tetanus of 13–14 year-old children (2nd year of compulsory secondary education). Our study cohort did not benefit from part of this strategy as, in 2002, when public health launched its vaccination proposal, they were already 15-years-old (3rd year of compulsory secondary education) and in this year interventions with routine vaccinations were not performed. They only had the opportunity to get themselves vaccinated by means of the information provided by posters distributed in health centres.
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This cohort from 1987 was also chosen because it was the last opportunity to be vaccinated as in 2007, the year of the intervention, they turned 20 and, according to the summary of product characteristics, this was the maximum permitted age for this vaccination.
Table 1 – Subjects under study before the intervention. Before the intervention N = 351
Vaccinated
Total Males N = 177 Females N = 174
14 (4.0%) 7 (4.0%) 7 (4.0%)
Not vaccinated 337 (96.0%) 170 (96.0%) 167 (96.0%)
The following were included in the study - All individuals born in 1987 belonging to the Rafalafena Health Centre. - Those who were not vaccinated with the meningococcal C conjugate vaccine. - Those who had a previous dose of the plain A + C polysaccharide vaccine.
- Individuals who had had an anaphylactic reaction to any previous dose of the vaccine. - Those who had shown hypersensitivity to any component of the vaccine. - Individuals who cannot read letters or understand telephone calls (physical disability, severe psychiatric disorder). - Pregnant and breastfeeding women. - Patients on systemic immunosuppressive therapy.
on the letter. The call was made by the health centre nursing personnel from the paediatric nursing clinic. The method used for the selection of letter or telephone call was carried out according to simple random sampling, thereby ensuring that each member of the population had the same probability of being selected as a subject. Patients who accepted came in the established time slots or were given an appointment in the paediatric nursing clinic where the vaccine was administered and it was registered in the Registro Nominal de Vacunas [Nominal Vaccination Registry] (RNV). They were informed of the intervention that was being carried out and of the purpose of it, inviting them to read and sign the consent for the research. The intervention was performed at the paediatric nursing clinic because the nurse was also head of vaccination at the centre. They were administered ® the Menjugate vaccine.
Vaccination of the adolescent is delayed
Ethical aspects
- If the patient has just received a meningococcal polysaccharide vaccine, a minimum interval of six months must be maintained in order to be able to administer the meningococcal C conjugate vaccine. - In acute disease, until the individual has recovered (due to the differential diagnosis in the event of the onset of a possible adverse reaction).
This study was performed following the recommendations and ethical principles established in the 1964 Declaration of Helsinki, and subsequent updates, in relation to medical research carried out with the participation of human subjects. The relevant authorisation was requested from the Chief Executive Officer of the Rafalafena Health Centre for the conduct of the intervention on participants, as well as the subsequent use of data. Authorisation was also requested to participate in the research, after ensuring that the patient had understood the information that he/she was given about the study objectives, benefits, discomforts and possible risks of the informed consent. In order to preserve the anonymity of the sample, patients were given a code when included in the study, so that no other identifying data concerning them appeared in any phase of the study.
The following were excluded from the study
Sample size It was decided to perform a pilot study for the calculation of the sample, taking for this 30 individuals who complied with the inclusion/exclusion criteria. Epidat v.3.1 was used for the calculation of the sample. According to the data, a 30% improvement in the vaccination rate was observed, which required 316 individuals for a 95% confidence interval, and a precision of 5%. In addition, if a 10% loss occurred, we would need 351 patients, so we included 100% of our sample. A 10% sample loss of subjects due to change of address or change of telephone number was presumed during the study period.
Results
Procedure
Characteristics of the study population
The educational intervention was performed during the first three months of 2007: one group was sent an educational letter aimed at patients by post (as they were of legal age), in DIN A4 format, in which the significance of meningococcal disease, as well as the efficacy and safety of vaccination against disease, was highlighted, indicating the contact telephone numbers in case of queries, as well as the time slots during which they could come to be vaccinated. This letter was drafted following the recommendations of the Centers for Disease Control and Prevention and the Regional Ministry of Health and Consumption of the Autonomous Region of Valencia. Another group of participants were called by telephone, offering them the same explanation as that which appeared
As can be observed in Table 1, 351 individuals were recruited initially. Of these, 177 were male and 174 female. Of the total size of the sample (N = 351), we found that 14 participants were immigrants (7 males and 7 females). The age of the subjects was 19–20 as they were all born in 1987. Prior to the educational intervention, a total of 14 vaccinated and registered individuals (7 males and 7 females) were found out of 351 susceptible subjects, with 337 non-vaccinated individuals, of whom 170 were males and 167 females. Of these 337, two individuals were lost to follow-up because personal data to contact them was not available. A sample of 335 therefore remained (Fig. 1).
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Table 3 – Codifications of categorical variables. N = 351
• Loss of 2 individuals due to lack of contact details
Parameter coding Immigrants
N = 349
Recruitment
• Less than 14 subjects who were already vaccinated and registered
N = 335
• Final sample
Fig. 1 – Summary of the evolution of the sample. Prepared by the authors.
Vaccination rate and registration after educational intervention for adolescents After the intervention, as shown in Table 2, from a sample of 335 participants, 171 (52.7%) got vaccinated and 164 (46.7%) did not get vaccinated. With these data, an increase in the vaccination rate of 49% was established (95% CI: 43.35–54.09). Of those vaccinated, 52.6% were males and 47.4% females, compared to 47.5% of males and 52.4% of females who did not get vaccinated. Regarding the educational intervention, it was revealed that 197 (58.8%) participants were contacted by letter, achieving the vaccination of 108 compared to 89 participants who did not get vaccinated, while 138 (41.2%) participants were contacted by telephone call, resulting in 63 adolescents getting vaccinated compared to 75 who did not get vaccinated (Table 1). No statistically significant differences were observed in the efficacy of the interventions. The total number of the sample was 351 individuals. Of these, two were lost to follow-up due to lack of contact details. Of the total of 349, 14 individuals who were already vaccinated and registered were identified. A total of 335 individuals who were not vaccinated or registered therefore remained. During the intervention, it was found that, of these 335, there were 19 adolescents who appeared as not vaccinated in the nominal registry, but when bringing the immunisation record, it was revealed that they were vaccinated against meningitis C, but they were not registered. As at this point of the study we were referring exclusively to the registration of the vaccination, an increase of 19 individuals was observed in the RNV.
Gender
1 0 1 0 1 0
Independent variable label Non-immigrant Immigrant Recruitment by letter Recruitment by telephone Male Female
An estimation for a proportion was performed, with a 95% confidence interval. After the intervention, an increase in the vaccination registration of 40.43% (N = 19) was seen, with a 95% CI: 25.33–55.52; p = 0.000.
Factors related to the compliance of the meningococcal vaccine By having a dichotomous dependent variable on which it was wished to evaluate the association or connection with other independent variables such as gender, immigrant or non-immigrant and recruited either by letter or by telephone contact, the procedure to be performed was a multivariate binary logistic regression. Table 3 shows the codification used in the independent variables. In this study, the variables selected were: gender, immigrants and method of recruitment (either by letter or by telephone contact). Table 4 displays the estimated parameter (B), its standard error (ET) and its statistical significance with the Wald test (statistic that follows a Chi-square law with a degree of freedom), and the OR calculation (Exp(B)). In this first block, only the constant appears in the regression equation, with the variables having remained outside. The proportion of variability of the “Compliance of the vaccine against meningococcal disease” explained by the following models which appear in Tables 6a–6c is not very good, as we can see a discrete Cox and Snell R2 of 0.027, which indicates that only 2.7% of the variation of the dependent variable, complying or not complying with the vaccination against meningococcal disease is explained by the variables included in the model (Table 5). By performing the correction with Nagelkerke’s R2 , we observed a result which was also discrete of 0.036 (3.6%). Therefore, there continued to be a significant percentage of “influence” on the fact of complying with the meningococcal vaccine which did not depend on the variables analysed. Finally, in Tables 6a–6c variables which would be left in the equation, their regression coefficients with their corresponding standard errors, the Wald statistical value to evaluate the
Table 2 – Informative interventions in the study population. After the intervention N = 335 2 (0.6%) losses
Not vaccinated 164 (46.7%) Males
Letter 197 (58.8%) Telephone 138 (41.2%)
78 (47.5%) 47 (60.3%) 31 (39.7%)
Vaccinated 171 (52.7%) Females
Males
86 (52.4%) 42 (48.8%) 44 (51.2%)
90 (52.6%) 51(56.7%) 39(43.3%)
Females 81 (47.4%) 57 (70.4%) 24 (29.6%)
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Table 4 – Equation variables.
Step 0
Constant
B
ET
Wald
df
Sig.
Lower 0.048
Upper 0.109
Lower 0.192
Upper 1
Lower 0.662
Exp(B) OR Upper 1.049
Table 5 – Summary of the models. Step
−2 log likelihood
Cox and Snell’s R2
Nagelkerke’s R2
1
453.738 (a)
0.027
0.036
Table 6a – Equation variables.
Step 1 (a)
IMMIGRANTS (1) Constant
B Low.
ET Upp.
Wald Low.
df Upp.
Sig. p Low.
Exp(B) Upp.
95% CI for EXP(B) Low.
Upp.
0.971 0.788
0.333 0.311
8.485 6.411
1 1
0.004 0.011
2.640 0.455
1.374
5.073
Log-likelihood of the model
Change in −2 log-likelihood
df
Sig. of change
−231.415
9.093
1
0.003
Table 6b – Model if the term is eliminated. Variable Step 1
Immigrants
Table 6c – Variables not in the equation.
Step 1
Variables
GENDER (1) RECRUITMENT (1)
Overall statistics
null hypothesis (Pi = 0), the associated statistical significance and the OR value (Exp(B)) with its confidence intervals appear and continue. As can be seen, only the “Immigrant” variable appears, as the statistical level of significance of the Wald test is 0.004, which indicates that it is a useful parameter for the model. The rest of the gender and recruitment variables were rejected because their level of significance was greater than 0.05. Therefore, we cannot reach any conclusion with these independent variables (Tables 6a–6c).
Determination of the number of educational interventions which have to be performed for the recruitment of one individual The number needed to treat (NNT) was calculated. The NNT was determined, defining it as the number of interventions necessary to achieve the vaccination of one person. The proportion of patients vaccinated before the intervention was 0.04, and the proportion of subjects after the intervention was 0.53. It was therefore estimated that we needed to perform an educational programme with three individuals in order to manage to recruit one.
Discussion After a search performed in PubMed, with the search strategy “Spain AND meningococcal AND vaccine”, this study is the
Score
df
Sig.
0.523 1.714 2.274
1 1 2
0.469 0.190 0.321
largest of this type of those carried out in Spain during this period of time (Table 7). Regarding the characteristics of participants in the study, males predominate, although in a percentage which is identical to the predominance of this gender in the population of the city of Castellón, in the same age range, according to official data of the Spanish National Statistics Institute (INE) in 2007. As in other studies performed with other vaccines,15–21 the conduct of a direct information activity is revealed as an effective method to increase vaccine coverage, much more so than indirect information through leaflets, posters, etc. As we can see in the study, active recruitment offers a 49% increase in vaccination, with a 95% CI and 40.43% increase in vaccination registration, with a 95% CI: 25.33–55.52. Szilagyi20 performed direct educational interventions (letter, telephone call) on a marginal adolescent population to increase vaccine coverage against serogroup C meningococcal disease, pertussis and human papilloma virus that obtained certain improvements (21% by letter, 17% by telephone and 13% control) with a low economic cost. The results obtained are modest in comparison with those of our study, although it also has to be borne in mind that, in this intervention, the socioeconomic status was not considered as a study variable, nor was it acted upon taking the study population only as a marginal population, meaning that it cannot be concluded that the difference in the results of both studies is the cause of being a population with low economic income. Chung,20 in his work on an adolescent population in a rural environment, in Duplin County (North Carolina), by means of
31
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Table 7 – Different studies published up to 2017. Author
Population
Instrument
Type of vaccine
Country
˜ Ibanez-Jimenez A, et al. (2007)9 Kolasa MS, et al. (2009)10 Cardemil CV, et al. (2016)11 Swallow W, Roberts JC (2016)12
24–30 years
Postal reminder
Tetanus-diphtheria
Spain
19 months
Letter and telephone
Routine vaccination
USA
19–35 months 13–17 years A secondary school
Registration of vaccines Vaccination schedule
USA
Cadena J, et al. (2016)13
Health workers
Influenza
Texas
Bay SL, Crawford DJ (2016)14
19 months Children with respiratory problems
Audit of information system suppliers 2 submissions of letters + email + telephone call from school nurse to parents Telephone message Message on screen e-Mail Letter and telephone
Routine vaccines
USA
direct interventions (post, telephone) obtained improvement compared to other comparable counties, in the vaccine coverage against meningitis C (of 34.6% prior to the intervention to 49.4% post-intervention). In his article they mention having a web-based vaccine registry (North Carolina Immunization Registry [NCIR]) and offering economic incentives to participating professionals for completion and economic evaluation of the interventions. Van der Meer et al. conclude in their study that by using an active method (personal letter) and a passive method (poster), minimal results are obtained in the second.22 In view of the study results, it can be concluded that the interventions aimed at adolescents related to vaccination programmes must be planned actively and directly, as it is a group that attends health centres little or very little. The nurse is the key member of personnel when doing educational interventions aimed at active recruitment. In different studies23–26 reference is made to the importance of the nurse as a facilitating agent to increase vaccine coverage, whether by reminder calls, as in the case of Whelan,24 or as school nurses in the case of Bobo25 and Pudelco et al.26 The importance of the nursing team in immunisation, coordination of programmes, planning, evaluation and monitoring of vaccination coverage is highlighted. Therefore, the results of our study coincide with the study hypothesis, as without the nursing intervention in the active search and after vaccination of the adolescents, these individuals would not have been vaccinated, as the year studied was the last year permitted by the summary of product characteristics. The Community Preventive Services Task Force confirms that the role of nursing is fundamental when increasing vaccine coverage. In 2015, the World Health Organization (WHO) published a technical guideline for the member states, with the support of the WHO Regional Office for Europe, to empower and increase the contribution of nurses to achieve the Health 2020 goals.27 In this guideline, nurses are proposed as key personnel for the comprehensive care of patients. Vaccination registration is an important topic as the nominal registry systems (Meningitis C Prevention Plan in the
USA
Autonomous Region of Valencia, 2002)28 are a fundamental element to perform monitoring of vaccine coverage, therefore being able to recruit at-risk population groups which have not been subject to recommended vaccinations. In the Autonomous Region of Valencia, the vaccination campaign against serogroup C meningococcal disease was implemented in 2000, but it was not until 2004 that it started to be used comprehensively, coinciding with the implementation of the Administrative Information System (SIA). We agree with the 2011 recommendations from the CDC29 in which the importance of registering vaccinations and the need for the information to be reflected in the patient’s medical history is emphasised. The usefulness of the registration for not giving extra doses, the requirement to register any adverse event after vaccination and the importance of giving parents or guardians a registration card, and informing them of the importance of this document, is also pointed out. A review performed by the Community Preventive Services Task Force in which 240 articles or summaries addressing this topic were included,30 makes it possible to confirm that the information systems support interventions effectively with regard to increasing the vaccination rates and their registration. After the intervention carried out at Rafalafena, a 49% increase in vaccine coverage was reached, thanks partly to having information systems available. As in the articles gathered by the Task Community, our study enabled it to be concluded that these information systems are useful for: 1. Determining the vaccination status of the population to facilitate the taking of clinical, epidemiological or management decisions. 2. Orientating the responses of public health to outbreaks of vaccine-preventable diseases. 3. Evaluating the coverage of the vaccination. 4. Facilitating the management and evaluation of vaccination programmes. No differences in response between males and females were found. However, a greater response was determined in the immigrant population, although this piece of information
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must be interpreted with caution as it was a very small and non-representative sample. No significant differences were found either between sending the message by letter or by telephone call. Like all epidemiological studies, this investigation has limitations. In the study conducted, the total number of immigrants of the sample is not representative of the general population, as all of them respond to recruitment performed for the study and, therefore, we cannot include it as a factor influencing vaccination. We need to carry out studies comparing the recruitment performed of immigrants against non-immigrant subjects. We assume that the study would have been more enriching if we had taken into account factors such as socio-cultural level, characteristics of the immigrant population, if alternative medicine was used and if they went to a private doctor.
Conflicts of interest The authors declare that they have no conflicts of interest.
references
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