- Email: [email protected]
Influenza immunization among resident physicians in an urban teaching hospital
ARTICLE IN PRESS American Journal of Infection Control ■■ (2015) ■■–■■
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief reports
Influenza immunization among resident physicians in an urban teaching hospital Mubdiul Ali Imtiaz MD a,*, Lawrence D. Budnick MD b, Andrew R. Berman MD c a
Department of Internal Medicine, Rutgers University, New Jersey Medical School, Newark, NJ Occupational Medicine Service, Department of Internal Medicine, Rutgers University, New Jersey Medical School, Newark, NJ c Division of Pulmonary and Critical Care Medicine and Allergic and Immunologic Diseases, Rutgers University, New Jersey Medical School, Newark, NJ b
Key Words: Resident physician influenza immunizations teaching hospital
We surveyed resident physicians (RPs) at an academic medical center to determine the rate of influenza vaccination and reasons for nonvaccination. The overall self-reported immunization rate of RPs in 20132014 was 76.7%, and the most common reason for not being vaccinated was lack of time to get immunized (38.6%). Making flu vaccination available in training hospitals and at convenient locations and times that take into account varying work schedules may increase compliance. © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Seasonal influenza is the leading cause of vaccine-preventable death in the United States. The Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices, and Society for Healthcare Epidemiology of America recommend that health care workers (HCWs) be vaccinated against influenza each year.1 Despite these recommendations, the nationwide vaccination rate among HCWs was only 75.2% in 2014,2 which is below the national Healthy People 2020 target for flu vaccination among HCWs of 90%.3 A significant portion of HCWs include resident physicians (RPs), who have direct contact with patients on a regular basis, which make the patients in acute care settings vulnerable to potential transmission of influenza from RPs. The purpose of this investigation is to determine the immunization rate for the 20132014 seasonal influenza vaccine among RPs at Rutgers University—New Jersey Medical School (RU-NJMS) and predictors for nonvaccination.
* Address correspondence to Mubdiul Ali Imtiaz, MD, Department of Internal Medicine, Rutgers University, New Jersey Medical School, University Hospital Building, Room I-354, 150 Bergen St, Newark, NJ 07103. E-mail address: [email protected] (M. Ali Imtiaz). Previous presentation: Presented as an abstract at the American Thoracic Society International Conference, May 15-20, 2015, Denver, CO. Funding/support: Supported by Rutgers University—New Jersey School of Medicine. Conflicts of interest: None to report.
METHODS Setting RPs were defined to be all individuals enrolled in a graduate medical education training program in a health care setting. There were 611 RPs enrolled in 47 postgraduate residency and fellowship programs at RU-NJMS during the 2013-2014 academic year. Influenza immunization was strongly recommended, but not mandatory, for RPs during 2013-2014.
Design A link to an online survey using a standardized, anonymous, self-administered questionnaire was e-mailed by the program chiefs to their respective RPs to collect demographic characteristics, influenza immunization status during the 2013-2014 and previous season, and reasons for nonvaccination. A total of 510 RPs had access to the online survey via e-mail from April 22August 21, 2014. The Institutional Review Board of the RU-NJMS approved this study.
Data analysis A bivariate comparison using χ2 test of independence or Fisher exact test was made between U.S. and international medical graduates (IMGs). The analysis was performed using the Social Science Statistics Web site.
0196-6553/© 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.10.029
ARTICLE IN PRESS M. Ali Imtiaz et al. / American Journal of Infection Control ■■ (2015) ■■–■■
2
RESULTS
Table 1 Characteristics of respondents by location of medical degree
Characteristics of participants Of the distributed questionnaires, 37.2% (190/510) were completed (Table 1). However, 12 questionnaires were each missing 1 response (reported as unknown in Table 1). Sex (P = .19), postgraduate year (P = .11), and race (P = .12) did not differ significantly between U.S. medical graduates and IMGs; however, the IMGs were significantly older (P < .01). Influenza immunization rate The overall self-reported immunization rate of RPs in 20132014 was 76.7%. The immunization rate did not differ by the location of medical school attended (P = .55) or sex (P = .69). Among the respondents, 95.8% had influenza vaccination in the past, and 83.1% received influenza vaccine during the 2012-2013 flu season. History of influenza vaccination ever and in 2012-2013 were both significantly associated with receiving the vaccine during the 20132014 season (P < .01 for both). Reasons for nonvaccination The most common reason for not being vaccinated (38.6%) was lack of time to get immunized (Fig 1). The most common cited motivating factors to be vaccinated during the next influenza season among the nonvaccinated RPs were making vaccinations in the workplace at convenient locations and times (43.2%), availability of mobile flu vaccination carts in hospital floors (40.9%), and establishing mandatory flu vaccination for employment (36.4%). DISCUSSION
Reasons for non-vaccination among NVRPs
Immunization is considered a primary method of reducing the burden of seasonal influenza.4 Historically, RPs are underrepresented in studies of influenza vaccination among HCWs, with only a small number of studies published recently. In these, the immunization rate among RPs in the United States ranged from 24%-99%.5-9 Also lacking are data regarding attitudes toward influenza vaccination and predictors for vaccination.
U.S. medical graduate (n = 144)
Characteristic Sex Male Female Unknown Postgraduate year 1 2 3 ≥4 Unknown Age (y) ≤25 26-30 31-35 ≥36 Unknown Race-ethnicity Asian Black White Other Unknown Ever vaccinated Unknown Vaccinated in 2012-2013 Unknown Vaccinated in 2013-2014 Nonvaccinated in 2013-2014 Unknown Intend to receive vaccine next season
International medical graduate (n = 45)
77 (53.5) 64 (44.4) 3 (2.1)
29 (64.4) 15 (33.3) 1 (2.2)
.1859
55 (38.2) 30 (20.8) 34 (23.6) 24 (16.7) 1 (0.7)
26 (57.8) 7 (15.6) 6 (13.3) 5 (11.1) 1 (2.2)
.1117
10 (6.9) 104 (72.2) 26 (18.1) 3 (2.1) 1 (0.7)
4 (8.9) 21 (46.7) 14 (31.1) 6 (13.3) 0 (0.0)
.0015
57 (39.6) 11 (7.6) 64 (44.4) 11 (7.6) 1 (0.7) 138 (95.8) 1 (0.7) 122 (84.7) 1 (0.7) 111† (77.1) 32 (22.2) 1 (0.7) 35 (24.3)
27 (60.0) 3 (6.7) 13 (28.9) 2 (4.4) 0 (0.0) 42 (93.3) 0 (0) 34 (75.6) 0 (0.0) 33 (73.3) 12 (26.7) 0 (0.0) 15 (33.3)
.1227
.3582 .2097 .5534
NOTE. Values are n (%) or as otherwise indicated. The survey response from a resident physician with unknown location of medical degree (n = 1) was excluded from the analysis. *The χ2 analysis did not include any unknown responses. †This includes 3 residents who took their influenza vaccine in September 2013 and responded no to the following question: Have you received influenza vaccine since October 1, 2013?
Do not have any chronic illnesses Did not know it was available Concerned about getting influenza from the vaccine Unconvinced of effectiveness of the vaccine Not at high risk of acquiring influenza Never had flu before Concerned about side effects of the vaccine Do not want flu vaccination Inconvenience of accessing vaccine program Lack of time to get immunized 0
P value*
5
10
15
20
25
Frequency of response
Fig 1. Reasons for nonvaccination among resident physicians in 2013-2014. Abbreviation: NVRP, nonvaccinated resident physician.
ARTICLE IN PRESS M. Ali Imtiaz et al. / American Journal of Infection Control ■■ (2015) ■■–■■
Our findings indicate that lack of time to get immunized was the most frequently cited reason for nonvaccination followed by inconvenience of accessing vaccine program. As early as 1994, lack of time was cited as the most common reason for refusing influenza vaccine.5 This finding was similarly reported by Bearman et al,6 Lester et al,7 and Wodi et al,8 who also demonstrated lack of time as the most important reason for nonvaccination. This is not an uncommon phenomenon among RPs, who tend to prioritize on tasks that require the most urgent attention. Acquiring influenza vaccination can be time consuming, and if not mandatory, may be postponed by RPs to a more convenient time. RPs in our study however did not share the same misconceptions and fears regarding influenza vaccine efficacy and toxicity that were reported in earlier studies of HCWs10 and were an often cited reason for nonvaccination. Among nonvaccinated RPs in our study, concerns about vaccine safety were uncommon. Perhaps the direct experience of ordering influenza vaccine for their own patients accounts for this difference between RPs and HCWs as a whole. Making vaccinations available in training hospitals and at convenient locations and times that take into account varying RP work schedules was found to be the most cited motivating factors for future vaccination among nonvaccinated RPs. Simplifying the vaccination process, such as making mobile units available throughout the day, should be considered to save RPs’ time. Such measures are more likely to be effective when applied in a multifaceted approach. In addition, instituting a mandatory influenza vaccine policy was felt to be a strong motivator for future vaccination by respondents in our study. This is consistent with a recent meta-analysis that demonstrated 85% of HCWs agreed with a mandatory vaccination program.10 RPs did not feel passive reminders for vaccination, such as recurrent e-mail notifications during the influenza season, communications from senior leadership, and annual conferences regarding risks and benefits of influenza vaccination, were effective ways to increase vaccination rates.
3
Our study showed a statistically significant relationship between influenza vaccination during the 2013-2014 season and immunization status of the previous flu season. This suggests that prior influenza immunization may be a reliable predictor of influenza vaccination in the future; however, annual reinforcement of the need for immunization is essential. The limitations of this study include potential bias in self-report, lack of vaccination records, and low participation rate.
References 1. Rebmann T, Wright KS, Anthony J, Knaup RC, Peters EB. Seasonal influenza vaccine compliance among hospital-based and nonhospital-based healthcare workers. Infect Control Hosp Epidemiol 2012;33:243-9. 2. Black CL, Yue X, Ball SW, Donahue SM, Izrael D, de Perio MA, et al. Influenza vaccination coverage among health care personnel-United States, 2013-14 influenza season. MMWR Morb Mortal Wkly Rep 2014;63:805-11. 3. Healthy People 2020. Immunization and infectious disease objectives. IID-12.9: increase the percentage of health care personnel who are vaccinated annually against seasonal influenza. 2008. Available from: https://www .healthypeople.gov/2020/topics-objectives/topic/immunization-andinfectious-diseases/objectives. Accessed June 23, 2015. 4. DeSante JE, Caplan A, Shofer F, Behrman AJ. Physician attitudes towards influenza immunization and vaccine mandates. Vaccine 2010;28:2517-21. 5. Nafziger DA, Herwaldt LA. Attitudes of internal medicine residents regarding influenza vaccination. Infect Control Hosp Epidemiol 1994;15:32-5. 6. Bearman G, Fuentes L, Van Vorenkamp JL, Drusin LM. Vaccination without documentation: influenza immunization among medical residents at a tertiarycare medical center. Infect Control Hosp Epidemiol 2003;24:626-8. 7. Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol 2003;24:839-44. 8. Wodi AP, Samy S, Ezeanolue E, Lamour R, Patel R, Budnick LD, et al. Influenza vaccine: immunization rates, knowledge, and attitudes of resident physicians in an urban teaching hospital. Infect Control Hosp Epidemiol 2005;26:86773. 9. Fedson DS. Influenza vaccination of medical residents at the University of Virginia: 1986 to 1994. Infect Control Hosp Epidemiol 1996;17:431-3. 10. Aguilar-Díaz Fdel C, Jiménez-Corona ME, Ponce-de-León-Rosales S. Influenza vaccine and healthcare workers. Arch Med Res 2011;42:652-7.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g
Brief reports
Influenza immunization among resident physicians in an urban teaching hospital Mubdiul Ali Imtiaz MD a,*, Lawrence D. Budnick MD b, Andrew R. Berman MD c a
Department of Internal Medicine, Rutgers University, New Jersey Medical School, Newark, NJ Occupational Medicine Service, Department of Internal Medicine, Rutgers University, New Jersey Medical School, Newark, NJ c Division of Pulmonary and Critical Care Medicine and Allergic and Immunologic Diseases, Rutgers University, New Jersey Medical School, Newark, NJ b
Key Words: Resident physician influenza immunizations teaching hospital
We surveyed resident physicians (RPs) at an academic medical center to determine the rate of influenza vaccination and reasons for nonvaccination. The overall self-reported immunization rate of RPs in 20132014 was 76.7%, and the most common reason for not being vaccinated was lack of time to get immunized (38.6%). Making flu vaccination available in training hospitals and at convenient locations and times that take into account varying work schedules may increase compliance. © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Seasonal influenza is the leading cause of vaccine-preventable death in the United States. The Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices, and Society for Healthcare Epidemiology of America recommend that health care workers (HCWs) be vaccinated against influenza each year.1 Despite these recommendations, the nationwide vaccination rate among HCWs was only 75.2% in 2014,2 which is below the national Healthy People 2020 target for flu vaccination among HCWs of 90%.3 A significant portion of HCWs include resident physicians (RPs), who have direct contact with patients on a regular basis, which make the patients in acute care settings vulnerable to potential transmission of influenza from RPs. The purpose of this investigation is to determine the immunization rate for the 20132014 seasonal influenza vaccine among RPs at Rutgers University—New Jersey Medical School (RU-NJMS) and predictors for nonvaccination.
* Address correspondence to Mubdiul Ali Imtiaz, MD, Department of Internal Medicine, Rutgers University, New Jersey Medical School, University Hospital Building, Room I-354, 150 Bergen St, Newark, NJ 07103. E-mail address: [email protected] (M. Ali Imtiaz). Previous presentation: Presented as an abstract at the American Thoracic Society International Conference, May 15-20, 2015, Denver, CO. Funding/support: Supported by Rutgers University—New Jersey School of Medicine. Conflicts of interest: None to report.
METHODS Setting RPs were defined to be all individuals enrolled in a graduate medical education training program in a health care setting. There were 611 RPs enrolled in 47 postgraduate residency and fellowship programs at RU-NJMS during the 2013-2014 academic year. Influenza immunization was strongly recommended, but not mandatory, for RPs during 2013-2014.
Design A link to an online survey using a standardized, anonymous, self-administered questionnaire was e-mailed by the program chiefs to their respective RPs to collect demographic characteristics, influenza immunization status during the 2013-2014 and previous season, and reasons for nonvaccination. A total of 510 RPs had access to the online survey via e-mail from April 22August 21, 2014. The Institutional Review Board of the RU-NJMS approved this study.
Data analysis A bivariate comparison using χ2 test of independence or Fisher exact test was made between U.S. and international medical graduates (IMGs). The analysis was performed using the Social Science Statistics Web site.
0196-6553/© 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.10.029
ARTICLE IN PRESS M. Ali Imtiaz et al. / American Journal of Infection Control ■■ (2015) ■■–■■
2
RESULTS
Table 1 Characteristics of respondents by location of medical degree
Characteristics of participants Of the distributed questionnaires, 37.2% (190/510) were completed (Table 1). However, 12 questionnaires were each missing 1 response (reported as unknown in Table 1). Sex (P = .19), postgraduate year (P = .11), and race (P = .12) did not differ significantly between U.S. medical graduates and IMGs; however, the IMGs were significantly older (P < .01). Influenza immunization rate The overall self-reported immunization rate of RPs in 20132014 was 76.7%. The immunization rate did not differ by the location of medical school attended (P = .55) or sex (P = .69). Among the respondents, 95.8% had influenza vaccination in the past, and 83.1% received influenza vaccine during the 2012-2013 flu season. History of influenza vaccination ever and in 2012-2013 were both significantly associated with receiving the vaccine during the 20132014 season (P < .01 for both). Reasons for nonvaccination The most common reason for not being vaccinated (38.6%) was lack of time to get immunized (Fig 1). The most common cited motivating factors to be vaccinated during the next influenza season among the nonvaccinated RPs were making vaccinations in the workplace at convenient locations and times (43.2%), availability of mobile flu vaccination carts in hospital floors (40.9%), and establishing mandatory flu vaccination for employment (36.4%). DISCUSSION
Reasons for non-vaccination among NVRPs
Immunization is considered a primary method of reducing the burden of seasonal influenza.4 Historically, RPs are underrepresented in studies of influenza vaccination among HCWs, with only a small number of studies published recently. In these, the immunization rate among RPs in the United States ranged from 24%-99%.5-9 Also lacking are data regarding attitudes toward influenza vaccination and predictors for vaccination.
U.S. medical graduate (n = 144)
Characteristic Sex Male Female Unknown Postgraduate year 1 2 3 ≥4 Unknown Age (y) ≤25 26-30 31-35 ≥36 Unknown Race-ethnicity Asian Black White Other Unknown Ever vaccinated Unknown Vaccinated in 2012-2013 Unknown Vaccinated in 2013-2014 Nonvaccinated in 2013-2014 Unknown Intend to receive vaccine next season
International medical graduate (n = 45)
77 (53.5) 64 (44.4) 3 (2.1)
29 (64.4) 15 (33.3) 1 (2.2)
.1859
55 (38.2) 30 (20.8) 34 (23.6) 24 (16.7) 1 (0.7)
26 (57.8) 7 (15.6) 6 (13.3) 5 (11.1) 1 (2.2)
.1117
10 (6.9) 104 (72.2) 26 (18.1) 3 (2.1) 1 (0.7)
4 (8.9) 21 (46.7) 14 (31.1) 6 (13.3) 0 (0.0)
.0015
57 (39.6) 11 (7.6) 64 (44.4) 11 (7.6) 1 (0.7) 138 (95.8) 1 (0.7) 122 (84.7) 1 (0.7) 111† (77.1) 32 (22.2) 1 (0.7) 35 (24.3)
27 (60.0) 3 (6.7) 13 (28.9) 2 (4.4) 0 (0.0) 42 (93.3) 0 (0) 34 (75.6) 0 (0.0) 33 (73.3) 12 (26.7) 0 (0.0) 15 (33.3)
.1227
.3582 .2097 .5534
NOTE. Values are n (%) or as otherwise indicated. The survey response from a resident physician with unknown location of medical degree (n = 1) was excluded from the analysis. *The χ2 analysis did not include any unknown responses. †This includes 3 residents who took their influenza vaccine in September 2013 and responded no to the following question: Have you received influenza vaccine since October 1, 2013?
Do not have any chronic illnesses Did not know it was available Concerned about getting influenza from the vaccine Unconvinced of effectiveness of the vaccine Not at high risk of acquiring influenza Never had flu before Concerned about side effects of the vaccine Do not want flu vaccination Inconvenience of accessing vaccine program Lack of time to get immunized 0
P value*
5
10
15
20
25
Frequency of response
Fig 1. Reasons for nonvaccination among resident physicians in 2013-2014. Abbreviation: NVRP, nonvaccinated resident physician.
ARTICLE IN PRESS M. Ali Imtiaz et al. / American Journal of Infection Control ■■ (2015) ■■–■■
Our findings indicate that lack of time to get immunized was the most frequently cited reason for nonvaccination followed by inconvenience of accessing vaccine program. As early as 1994, lack of time was cited as the most common reason for refusing influenza vaccine.5 This finding was similarly reported by Bearman et al,6 Lester et al,7 and Wodi et al,8 who also demonstrated lack of time as the most important reason for nonvaccination. This is not an uncommon phenomenon among RPs, who tend to prioritize on tasks that require the most urgent attention. Acquiring influenza vaccination can be time consuming, and if not mandatory, may be postponed by RPs to a more convenient time. RPs in our study however did not share the same misconceptions and fears regarding influenza vaccine efficacy and toxicity that were reported in earlier studies of HCWs10 and were an often cited reason for nonvaccination. Among nonvaccinated RPs in our study, concerns about vaccine safety were uncommon. Perhaps the direct experience of ordering influenza vaccine for their own patients accounts for this difference between RPs and HCWs as a whole. Making vaccinations available in training hospitals and at convenient locations and times that take into account varying RP work schedules was found to be the most cited motivating factors for future vaccination among nonvaccinated RPs. Simplifying the vaccination process, such as making mobile units available throughout the day, should be considered to save RPs’ time. Such measures are more likely to be effective when applied in a multifaceted approach. In addition, instituting a mandatory influenza vaccine policy was felt to be a strong motivator for future vaccination by respondents in our study. This is consistent with a recent meta-analysis that demonstrated 85% of HCWs agreed with a mandatory vaccination program.10 RPs did not feel passive reminders for vaccination, such as recurrent e-mail notifications during the influenza season, communications from senior leadership, and annual conferences regarding risks and benefits of influenza vaccination, were effective ways to increase vaccination rates.
3
Our study showed a statistically significant relationship between influenza vaccination during the 2013-2014 season and immunization status of the previous flu season. This suggests that prior influenza immunization may be a reliable predictor of influenza vaccination in the future; however, annual reinforcement of the need for immunization is essential. The limitations of this study include potential bias in self-report, lack of vaccination records, and low participation rate.
References 1. Rebmann T, Wright KS, Anthony J, Knaup RC, Peters EB. Seasonal influenza vaccine compliance among hospital-based and nonhospital-based healthcare workers. Infect Control Hosp Epidemiol 2012;33:243-9. 2. Black CL, Yue X, Ball SW, Donahue SM, Izrael D, de Perio MA, et al. Influenza vaccination coverage among health care personnel-United States, 2013-14 influenza season. MMWR Morb Mortal Wkly Rep 2014;63:805-11. 3. Healthy People 2020. Immunization and infectious disease objectives. IID-12.9: increase the percentage of health care personnel who are vaccinated annually against seasonal influenza. 2008. Available from: https://www .healthypeople.gov/2020/topics-objectives/topic/immunization-andinfectious-diseases/objectives. Accessed June 23, 2015. 4. DeSante JE, Caplan A, Shofer F, Behrman AJ. Physician attitudes towards influenza immunization and vaccine mandates. Vaccine 2010;28:2517-21. 5. Nafziger DA, Herwaldt LA. Attitudes of internal medicine residents regarding influenza vaccination. Infect Control Hosp Epidemiol 1994;15:32-5. 6. Bearman G, Fuentes L, Van Vorenkamp JL, Drusin LM. Vaccination without documentation: influenza immunization among medical residents at a tertiarycare medical center. Infect Control Hosp Epidemiol 2003;24:626-8. 7. Lester RT, McGeer A, Tomlinson G, Detsky AS. Use of, effectiveness of, and attitudes regarding influenza vaccine among house staff. Infect Control Hosp Epidemiol 2003;24:839-44. 8. Wodi AP, Samy S, Ezeanolue E, Lamour R, Patel R, Budnick LD, et al. Influenza vaccine: immunization rates, knowledge, and attitudes of resident physicians in an urban teaching hospital. Infect Control Hosp Epidemiol 2005;26:86773. 9. Fedson DS. Influenza vaccination of medical residents at the University of Virginia: 1986 to 1994. Infect Control Hosp Epidemiol 1996;17:431-3. 10. Aguilar-Díaz Fdel C, Jiménez-Corona ME, Ponce-de-León-Rosales S. Influenza vaccine and healthcare workers. Arch Med Res 2011;42:652-7.