Factors contributing to declination of annual influenza vaccination by healthcare workers caring for cancer patients: An Australian experience

Factors contributing to declination of annual influenza vaccination by healthcare workers caring for cancer patients: An Australian experience

Vaccine 36 (2018) 1804–1807 Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Short communication...

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Vaccine 36 (2018) 1804–1807

Contents lists available at ScienceDirect

Vaccine journal homepage: www.elsevier.com/locate/vaccine

Short communication

Factors contributing to declination of annual influenza vaccination by healthcare workers caring for cancer patients: An Australian experience T.C. Surtees a,⇑,1, B.W. Teh a,b, M.A. Slavin a,b,c, L.J. Worth a,b,c,d a

Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia National Centre for Infections in Cancer, National Health and Medical Research Council Centre for Research Excellence, The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia c Department of Medicine, University of Melbourne, Melbourne, VIC, Australia d Victorian Healthcare Associated Infection Surveillance System (VICNISS), Doherty Institute, Melbourne, VIC, Australia b

a r t i c l e

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Article history: Received 16 October 2017 Received in revised form 16 February 2018 Accepted 22 February 2018 Available online 2 March 2018 Keywords: Influenza vaccination Healthcare worker Declination forms

a b s t r a c t Healthcare workers (HCWs) at an Australian cancer centre were evaluated using a voluntary declination form program to determine factors contributing to declination of annual influenza vaccination. Overall, 1835/2041 HCWs (89.9%) completed a consent or declination form; 1783 were vaccinated and 52 declined. Staff roles with minimal patient contact were significantly associated with lower vaccine uptake (adjusted odds ratio 0.48, 95% confidence interval 0.23–0.99). Reasons for vaccine refusal included personal choice (41%), previous side-effect/s (23.1%), and medical reasons (23.1%). Of these, a large proportion may not be amenable to intervention, and this must be considered in setting threshold targets for future campaigns. Published by Elsevier Ltd.

1. Introduction Seasonal influenza vaccination of healthcare workers (HCWs) prevents transmission of influenza between patients and staff [1], and is also associated with reduced patient mortality [2], healthcare costs [3,4] and staff absenteeism [5]. Despite benefits, uptake is frequently poor [6], and vaccination declination form programs (DFPs) have been proposed as a means of increasing vaccination uptake in HCW populations. Programs typically require HCWs wishing to decline vaccination to acknowledge risks associated with noncompliance and the rationale for vaccination, before signing a written declination statement [7,8]. Specific reasons for vaccine refusal can be assessed and used to inform targeted interventions [7,9,10]. Despite widespread use in influenza campaigns, studies examining the contribution of DFPs to vaccination rates are limited [11]. Although the use of declination forms has been adopted by some Australian healthcare facilities [12], the nature and outcome ⇑ Corresponding author at: Department of Infectious Diseases and Infection Prevention, Peter MacCallum Cancer Centre, Locked Bag 1 A’Beckett Street, Melbourne, Victoria 8006, Australia. E-mail address: [email protected] (T.C. Surtees). 1 Present address: Center for Threat Preparedness, West Virginia Department of Health and Human Resources, 505 Capitol Street, Suite 200, Charleston, WV 25301, United States. https://doi.org/10.1016/j.vaccine.2018.02.098 0264-410X/Published by Elsevier Ltd.

of DFPs have not been well described. The objectives of this study were therefore to: (1) explore the characteristics and predictors of HCWs declining vaccination compared to HCWs vaccinated under an existing influenza vaccination program consisting of a DFP in an Australian tertiary healthcare facility, and (2) to investigate the reported reasons for declination of vaccination, particularly those amenable to education or future interventions. 2. Methods 2.1. Study site The Peter MacCallum Cancer Centre (PMCC) is a tertiary referral hospital in Victoria, Australia specialised in care of cancer patients. Medical oncology, haematology, surgical oncology, and radiation oncology services are provided. 2.2. Vaccination program A multifaceted staff influenza vaccination program is implemented annually, including provision of free vaccine, use of mobile carts, and weekend clinics. Posters, electronic reminders and prompts on employee payslips are used to raise staff awareness. In 2014, an annual influenza vaccination uptake of 75% was set as a performance indicator by the Victorian Department of Health

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and Human Services for all public healthcare facilities, including PMCC [13]. Since 2009, a DFP has been utilised as part of annual PMCC vaccination campaigns. HCWs opting to decline vaccination for medical or other reasons must discuss the risks with their manager and complete a vaccine declination form (Fig. 1). Staff choosing to receive vaccination are requested to complete a consent form. Those vaccinated externally (another facility or by primary healthcare provider) are asked to provide documentation via email or to confirm vaccination directly to PMCC infection prevention staff. No punitive actions are taken against HCWs who fail to comply with the program; however, in the event of exposure to a patient with

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influenza, non-compliant staff must seek medical review prior to recommencing clinical duties. 2.3. Study design For the current study, all data captured through staff consent and declination forms were evaluated for the 2016 HCW influenza vaccination campaign (4 April to 29 July). All completed forms were collated by infection prevention staff. HCWs vaccinated externally or who informally reported receiving or declining vaccination were not included, as questionnaire data were unavailable.

Fig. 1. Healthcare worker influenza vaccination declination form.

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2.4. Definitions National Health and Medical Research Council (NHMRC) HCW risk categories were used to classify staff [14]: Category A—direct contact with or potential exposure to blood or body substances; Category B—indirect contact or rare exposure to blood and body substances; Category C—Minimal patient contact; and Laboratory staff. Self-reported profession, department, and patient contact information were obtained from completed forms and used to facilitate classification into an appropriate risk category. For the current study, two blinded investigators (LW and BT) independently categorised all participants into risk groups according to standardised criteria; combined consensus was reached for all HCWs. 2.5. Analysis Univariate and multivariate logistic regression modelling was used to assess the association between predictor variables and vaccination status. Firth logistic regression was used to account for separation of predictor variables [15]. The outcome variable assessed was receiving the quadrivalent influenza vaccination during the 2016 influenza campaign. Explanatory variables available for inclusion into the models were: age (years), NHMRC riskclassification, and presence of an egg allergy. All statistical analyses were conducted using Stata (version 14.1, StataCorp, College Station, TX). Qualitative analysis of the subgroup of HCWs who declined vaccination and completed the declination form was conducted to identify potential barriers to vaccination. HCW-stated reasons were categorised into themed groups: previous vaccine sideeffects, personal choice, minimal patient contact or self-assessed to not be at risk for influenza transmission, rarely sick, vaccine regarded as ineffective or concerns over side-effects, medical reasons, and needle phobia. Of these, study investigators (TS, BT, MS and LW) nominated potentially modifiable and non-modifiable factors through adapting classifications employed by previous studies [16,17]. 3. Results 3.1. Study population During the 2016 vaccination campaign, 2041 HCWs were employed at PMCC, and 1835 (89.9%) completed either an influenza vaccination consent or declination form and were evaluated. Of those completing a form, 1783 (97.2%) were vaccinated and 52 (2.8%) declined vaccination. Table 1 summarises characteristics of studied HCWs. Median age was 38 years (IQR: 31–51 years), and there was no significant difference in ages of HCWs who consented compared with those who declined vaccination (p = 0.58). The majority of HCWs (61.3%) belonged to NHMRC category A. However, a larger proportion of unvaccinated HCWs compared to vaccinated HCWs fell into category C (26.9% vs. 21.5%). Laboratory staff comprised less than 5% of total HCWs, and no laboratory workers declined vaccination. 3.2. HCW characteristics associated with vaccine uptake On univariate analysis, only the presence of an egg allergy was found to be significantly associated with reduced odds of vaccination (OR 0.03, 95% confidence interval [CI] 0.01–0.11; p < 0.001). Multivariate logistic regression modelling identified NHMRC category C status to be significantly associated with a lower vaccination uptake (adjusted OR 0.48, 95% CI 0.23–0.99; p < 0.05). The

Table 1 Characteristics of studied healthcare workers. Characteristic

All HCWs (n = 1835)

Vaccinated (n = 1783)

Declined vaccination (n = 52)

Age (years)a

38 (31–51)

38 (31–51)

40 (31.5–49)

NHMRC categoryb A B C Lab Not classifiable

1125 (61.31%) 222 (12.10%) 398 (21.69%) 88 (4.80%) 2 (0.11%)

1093 (61.30%) 216 (12.11%) 384 (21.54%) 88 (4.94%) 2 (0.11%)

32 (61.54%) 6 (11.54%) 14 (26.92%) 0 (0%) 0 (0%)

Egg allergyb No Yes Not reported

1822 (99.29%) 11 (0.60%) 2 (0.11%)

1775 (99.55%) 6 (0.34%) 2 (0.11%)

47 (90.38%) 5 (9.62%) 0 (0%)

HCW, healthcare worker; NHMRC, National Health and Medical Research Council. a Median (IQR). b n (%).

presence of an egg allergy was associated with reduced odds of vaccination (adjusted OR 0.04, 95% CI 0.01–0.15; p < 0.001). Age was not predicative of vaccination status in the multivariate model (p = 0.62). 3.3. HCW-stated reasons for vaccine declination Of the 52 declination forms, 39 contained reasons for declination. Leading reasons included personal choice (41%), previous side effect(s) of vaccination (23.1%), and medical reasons (23.1%). Of the 9 participants who declined vaccination for medical reasons, 5 reported egg allergies, 1 reported a history of GBS, and 3 reported unspecified medical contraindications. Table 2 summarises HCWreported reasons for declination. 4. Discussion We report the first detailed evaluation of factors contributing to HCW declination of annual influenza vaccination at an Australian healthcare facility utilising a DFP as part of a multimodal vaccination campaign. Findings confirm known factors associated with vaccination declination, such as egg allergies. We also observed HCWs having less clinical contact to be more highly represented in the non-vaccinated cohort. Reasons for declination included potentially modifiable and non-modifiable factors, and these were comparable to previous studies [9,16,17]. Previous side-effects, needle phobia and medical reasons comprised approximately 50% of stated reasons for vaccine refusal (Table 2). Arguably, these may not be amenable to further intervention, and these HCWs could be regarded as remaining unvaccinated in future campaigns. While some remaining factors

Table 2 Self-reported reasons for opting to not receive influenza vaccination. Reason

Number of HCWs (%)a

Previous side effect(s) of vaccination Personal choice Self-reported minimal patient contact or not at risk Rarely sick Believe vaccine to be ineffective or risky Medical reasonb Needle phobia Other

9 (23.1%) 16 (41.0%) 3 (7.7%) 1 (2.6%) 1 (2.6%) 9 (23.1%) 2 (5.1%) 1 (2.6%)

HCW, healthcare worker. a Total exceeds 100% due to n = 3 responses encompassing >1 theme. b Medical reasons include history of Guillain-Barré syndrome, egg allergy, and unspecified medical contraindications.

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could be amenable to targeted education (e.g. belief that vaccine is ineffective or risky) [16], the majority (41%) were reported as ‘personal reasons’, meaning staff were unable to or had preference not to disclose their specific attitudes or beliefs for vaccine refusal. Further qualitative study of HCWs’ attitudes and beliefs could enhance our classification of modifiable and non-modifiable factors, and attempts should be made in future studies to confirm that selfreported medical reasons represent true contraindications. Declination forms may be more likely adopted in facilities where HCWs are motivated to support vaccination programs, and therefore may reflect an association with, rather than a cause of, higher vaccination uptake [18]. Our experience with DFPs has spanned seven years in the setting of multimodal campaigns, so declination forms alone cannot clearly be aligned with high vaccine uptake. During the 2016 campaign, a large proportion of staff (approximately 90%) completed declination or consent forms. Some of the remaining staff communicated vaccination status or intention via other means (e.g. e-mail or telephone), but were not included in the current study. On the basis of forms received, vaccine uptake was 87.4% among all staff. However, this is likely an underestimation of true vaccine uptake. When all responses were evaluated, including vaccination status communicated by other means, vaccine uptake was 92.4% (data not shown). Although the PMCC staff influenza vaccination program is non-mandatory, these findings reflect an organisational focus upon quality improvement. A limitation of this study is the fact that retrospective data were evaluated, and quality of data was reliant upon self-reporting. Results may reflect a biased representation of HCWs – namely those who are motivated and prepared to complete declination forms. Indeed, we were unable to evaluate those HCWs who did not complete either consent or declination forms (approximately 10% of staff), and future campaigns will seek to ensure that vaccine status of all employed staff is monitored through formal reporting. Also, the nature of the study site must be considered. Being a specialist centre responsible for care of immunocompromised patients, staff may have unique or systematically different outlook regarding vaccination. Increased risk of severe and complicated influenza infection in cancer populations is widely accepted and has been reported at our facility [19,20]. Staff may consider these risks when making personal decisions regarding their own vaccination. Vaccine uptake is historically very high at our facility [21,22], meaning non-vaccinated staff comprise a minority of total employed staff. Looking ahead, a small increase in vaccination uptake could be achieved through targeted interventions, such as education regarding vaccine effectiveness and low-risk of vaccine-related adverse events [10]. We plan to incorporate these into forthcoming campaigns, recognising that the clinical impact may be limited, given that a large proportion of unvaccinated staff have minimal patient contact. Findings also suggest that our facility has reached the ‘upper threshold’ of vaccine uptake achievable using a non-mandatory approach, as many factors associated with declination were not amenable to intervention. This should be considered in the setting future healthcare performance indicators based on HCW vaccination uptake [23]. Acknowledgements Jennifer Breen, Susan Harper and Thu Nguyen are acknowledged for collation of consent and declination forms throughout the vaccination program.

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Conflict of interest None. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References [1] Kuster SP, Shah PS, Coleman BL, Lam P-P, Tong A, Wormsbecker A, et al. Incidence of influenza in healthy adults and healthcare workers: a systematic review and meta-analysis. PLoS One 2011;6(10):e26239. [2] Ahmed F, Lindley MC, Allred N, Weinbaum CM, Grohskopf L. Effect of influenza vaccination of healthcare personnel on morbidity and mortality among patients: systematic review and grading of evidence. Clin Infect Dis 2013;58 (1):50–7. [3] Maltezou HC. Nosocomial influenza: new concepts and practice. Curr Opin Infect Dis 2008;21(4):337–43. [4] Serwint JR, Miller RM. Why diagnose influenza infections in hospitalized pediatric patients? Pediatr Infect Dis J 1993;12(3):200–3.5. [5] Wilde JA, McMillan JA, Serwint J, Butta J, O’Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281(10):908–13. [6] Rizzo C, Rezza G, Ricciardi W. Strategies in recommending influenza vaccination in Europe and US. Hum Vaccin Immunother 2017:1–6. [7] LaVela SL, Hill JN, Smith BM, Evans CT, Goldstein B, Martinello R. Healthcare worker influenza declination form program. Am J Infect Control 2015;43 (6):624–8. [8] McLennan S, Wicker S. Reflections on the influenza vaccination of healthcare workers. Vaccine 2010;28(51):8061–4. [9] Ribner BS, Hall C, Steinberg JP, Bornstein WA, Chakkalakal R, Emamifar A, et al. Use of a mandatory declination form in a program for influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol 2008;29(4):302–8. [10] To KW, Lai A, Lee KC, Koh D, Lee SS. Increasing the coverage of influenza vaccination in healthcare workers: review of challenges and solutions. J Hosp Infect 2016;94(2):133–42. [11] Weinstein RA, Talbot TR. Do declination statements increase health care worker influenza vaccination rates? Clin Infect Dis 2009;49(5):773–9. [12] Seale H, Kaur R, MacIntyre CR. Understanding Australian healthcare workers’ uptake of influenza vaccination: examination of public hospital policies and procedures. BMC Health Serv Res 2012;12(1):325. [13] Johnson SA, Bennett N, Bull AL, Richards MJ, Worth LJ. Influenza vaccination uptake among Victorian healthcare workers: evaluating the success of a statewide program. Aust N Z J Public Health 2016;40(3):281–3. [14] National Health and Medical Research Council. Australian guidelines for the prevention and control infection in healthcare (2010); 2010. Available from: [accessed 22 September 2017]. [15] Heinze G, Schemper M. A solution to the problem of separation in logistic regression. Stat Med 2002;21(16):2409–19. [16] Chen SC, Hawkins G, Aspinall E, Patel N. Factors influencing uptake of influenza A (H1N1) vaccine amongst healthcare workers in a regional pediatric centre: lessons for improving vaccination rates. Vaccine 2012;30(2):493–7. [17] Alkuwari MG, Aziz NA, Nazzal ZA, Al-Nuaimi SA. Pandemic influenza A/H1N1 vaccination uptake among health care workers in Qatar: motivators and barriers. Vaccine 2011;29(11):2206–11. [18] Weinstein ND, Kwitel A, McCaul KD, Magnan RE, Gerrard M, Gibbons FX. Risk perceptions: assessment and relationship to influenza vaccination. Health Psychol 2007;26(2):146–51. [19] Teh BW, Worth LJ, Harrison SJ, Thursky KA, Slavin MA. Risks and burden of viral respiratory tract infections in patients with multiple myeloma in the era of immunomodulatory drugs and bortezomib: experience at an Australian Cancer Hospital. Support Care Cancer 2015;23(7):1901–6. [20] Tramontana AR, George B, Hurt AC, Doyle JS, Langan K, Reid AB, et al. Oseltamivir resistance in adult oncology and hematology patients infected with pandemic (H1N1) 2009 virus, Australia. Emerg Infect Dis 2010;16 (7):1068–75. [21] Leung VK, Carolan LA, Worth LJ, Harper SA, Peck H, Tilmanis D, et al. Influenza vaccination responses: evaluating impact of repeat vaccination among health care workers. Vaccine 2017;35(19):2558–68. [22] Leung VK, Harper SE, Slavin MA. Influenza vaccination uptake in an Australian hospital: time to make it mandatory for health care workers? Med J Aust 2012;197(10):552. [23] Johnson SA, Wang D, Bennett N, Bull AL, Richards MJ, Worth LJ. Influenza vaccination of Australian healthcare workers: strategies to achieve high uptake. Aust N Z J Public Health 2017.