- Email: [email protected]
99
Vaccine 18 (2000) 2471±2475
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In¯uenza vaccination coverage in old people's home in Carmarthenshire, UK, during the winter of 1998/99 A. Gupta a,*, G. Morris a, P. Thomas b, M. Hasan c a
Prince Phillip Hospital, Llanelli SA14 8QF, UK Carmarthenshire NHS Trust, Prince Phillip Hospital, Llanelli SA14 8QF, UK c University of Wales College of Medicine, Llandough Hospital, Penarth CF64 2XX, UK b
Received 2 June 1999; received in revised form 6 January 2000; accepted 1 February 2000
Abstract A mailed questionnaire survey was undertaken in old people's (nursing and residential) homes in Carmarthenshire, UK to determine the in¯uenza vaccine uptake during the 1998/99 season. Out of the total 60 questionnaires circulated, response was received from 47 homes giving an overall response rate of 78%. Amongst the 1399 residents, 1132 (81%) received in¯uenza vaccine in the winter of 1998/99. Uptake was higher in nursing homes (89%) than in residential homes (79%) or dual registered homes (81%). The most common reason for not receiving in¯uenza vaccination was refusal by the residents themselves, although the vaccine was oered to 99% of residents. This study suggests that strategies to improve communication and provision of educational materials outlining the bene®ts of in¯uenza vaccine to elderly residents and health professionals may help increase the likelihood of vaccine uptake. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: In¯uenza immunisation; Residential and nursing homes; Elderly
1. Introduction In¯uenza remains a major cause of morbidity and mortality. People at greatest risk are the elderly, those with chronic disease and those in residential and long stay homes [1]. During the 1989/90 in¯uenza epidemic, 26,000 in¯uenza related deaths occurred in the UK, with the mortality being highest in older adults living in institutional settings [2]. Outbreaks of in¯uenza in long stay institutions may cause illness in 70% of the residents and up to 22% of those aected develop complications severe enough to result in hospitalisation or death [3]. In¯uenza vaccination prevents in¯uenza related hospitalisation and death amongst nursing home residents [3±6]. A meta-analysis of 16 studies of in¯uenza vac* Corresponding author. Tel.: +0044-01554-756567; fax: +004401554-749527. E-mail address: [email protected] (A. Gupta).
cine in the elderly revealed a 67% reduction in mortality [7]. Moreover, several studies worldwide have clearly demonstrated the cost eectiveness of an in¯uenza immunisation programme in the prevention of in¯uenza and related morbidity in the elderly [8±11]. In the USA, Canada and most European countries, national health policies recommend vaccination of all persons above the age of 65 yr regardless of their health status [12]. In the UK, in¯uenza vaccination is annually recommended for all residents of nursing homes, residential homes and other long stay facilities where rapid spread is likely to follow the introduction of in¯uenza [13] [Appendix A]. Despite the bene®ts of immunisation and despite the guidelines, uptake of vaccination in elderly people in institutional settings remains poor [14±17]. Thus many vaccine preventable deaths and many vaccine preventable hospitalisations from elderly homes continue to occur every year. The recently published UK Department of Health guidelines on in¯uenza immunisation
0264-410X/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 6 4 - 4 1 0 X ( 0 0 ) 0 0 0 4 8 - 7
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A. Gupta et al. / Vaccine 18 (2000) 2471±2475
recommend that the vaccine should be oered to all individuals above the age of 75 yr [18]. However, it is not clear whether this has in¯uenced the practice in any way. We undertook this study to measure the in¯uenza vaccine coverage in nursing and residential homes for elderly people in the Carmarthenshire region (UK) during the winter of 1998/99. We are not aware of a similar study in institutionalised elderly residents undertaken in the UK during the winter of 1998/99 since the introduction of October 1998 guidelines by the Department of Health [18]. 2. Methods Ethical approval for the study was obtained from Dyfed Powys Ethics Committee. The Carmarthenshire district in South Wales, UK has a population of 169,000 and there are 60 nursing and residential homes. In December 1998, a postal questionnaire (copies available from the author) and a covering letter was sent along with a stamped addressed envelope to the matron or ocer in charge of each home. Non-responders were reminded by telephone. Information was sought on the in¯uenza vaccination status of all elderly persons resident at the home on 1st January 1999. The questionnaire required information regarding the status of the home (nursing, residential or dual registered), the number of residents present, number vaccinated during the winter of 1998/ 99 and the reasons for those non-vaccinated. The data was entered in an IBM personal computer for processing and analysis. Responses were summarised and percentage frequencies were determined for the response. 3. Results Of the 60 questionnaires sent out, 47 (78.3%) were completed and returned. The information received cov-
Table 1 In¯uenza vaccination coverage in the 47 homes which responded Percentage of residents immunised
Number (%) of homes with uptake rate
< 50 50±59 60±69 70±79 80±89 90±99 100 Total
5 5 4 3 10 13 7 47
(10.6%) (10.6%) (8.5%) (6.4%) (21.3%) (27.7%) (14.9%) (100%)
ered 1399 residents ranging from 7 to 107 residents per home. Of the 1399 residents, 1132 residents received in¯uenza vaccination during the winter of 1998/99 (81% uptake). Table 1 shows the coverage of in¯uenza vaccination in homes studied. The uptake rate varied from seven homes achieving 100% immunisation coverage to one home with the lowest rate of 38%. Five homes had below 50% vaccination uptake. Table 2 illustrates the percentage of residents vaccinated according to the categories of homes. Of the four homes registered as nursing homes, in¯uenza vaccine was received by 136 out of 153 residents (89% uptake). Of the 33 residential homes, 614 of 774 residents were vaccinated (79%). Amongst dual registered homes, vaccination coverage was 81% in 382 of the 472 residents. Table 3 illustrates the reasons for non-vaccination. The most common reason for non-vaccination was refusal by the residents themselves in 157 (59%) residents. It is noted that only <1% of the study population were not oered vaccine. The pattern of reasons for not vaccinating/being vaccinated were the same for homes in the lower range of uptake scale and for institutions with high uptake rates and the results were statistically non-conclusive. 4. Discussion This study demonstrates a mean in¯uenza vaccine uptake of 81% amongst 1399 elderly residents of 47 nursing and residential homes in Carmarthenshire, UK, during the winter of 1998/99. Previous UK studies have shown an in¯uenza vaccine uptake of 45% in Leicestershire in 1988/89 [14], 67% in South Glamorgan in 1991/92 [15], 40% in Nottingham in 1992/93 [16] and 77% in South Glamorgan in 1995 [17] amongst the residents of old people's homes. It appears that in recent years, there is a trend towards improved vaccination coverage in institutionalised people. It is not exactly clear from our study what led to such a high vaccine uptake. We feel that the better uptake could be related to an improved awareness of the bene®ts of in¯uenza vaccination by the primary care sta and residents of these homes. We believe that it is too early for the recent UK guidelines [18] to have its impact on vaccination coverage. Table 4 shows the demographics of residents in previous UK studies examining the in¯uenza vaccination coverage. The population groups are non-homogenous in terms of age and size of the populations and this could account for the dierent uptake rates. However, in South Glamorgan studies [15,17] there was no relation observed between in¯uenza immunisation in dierent homes and the age, sex, number of residents,
A. Gupta et al. / Vaccine 18 (2000) 2471±2475
2473
Table 2 Vaccination status according to the type of home Type of home
Number of residents
Number (%) vaccinated
Number (%) not vaccinated
Residential Nursing Dual registered Total
774 153 472 1399
614 136 382 1132
160 17 90 267
length of residence, whether immunised at home or at the GP surgery. We have demonstrated a slightly better uptake in nursing homes than in residential homes and this was also noted in a previous study [15]. We did not ascertain the underlying illness or the medical risk factors associated with in¯uenza vaccination because in¯uenza immunisation is recommended for all residents in nursing and residential homes regardless of their age and health status [13]. Appendix A outlines the groups recommended for in¯uenza vaccination by the Department of Health, UK, therefore risk factors should not in¯uence the decision to vaccinate. Moreover, previous studies have reported for all residents to have one or more indications for vaccination and additional risk factors were present in more than 70% of residents [14]. All homes in the UK are subject to regular inspections for registration purposes under the Registered Homes Act of 1984. This ensures that the homes keep a proper record of vaccination coverage. The Association for In¯uenza Monitoring and Surveillance has issued a policy pack for nursing and residential homes, which encourages sta to promote in¯uenza immunisation of residents and keep proper immunisation records [19]. However, there is a large variability in policies for promoting in¯uenza vaccination in old people's homes throughout England and Wales. In the Nottingham study, 52% of the homes claimed to operate a policy for in¯uenza immunisation but only 12% had a written down policy and none set targets for vaccine uptake [16]. Studies have suggested that the presence of a policy for in¯uenza vaccination by the general practitioners is an important factor which determines the vaccine uptake [20]. Prospective moniTable 3 Showing the reasons for non-vaccination Reason for non-vaccination
Number (%) of residents
Refused by resident Refused by relative Unwell De®nite allergy in past Never oered Unknown Total
157 34 51 6 10 9 267
(58.8%) (12.7%) (19.1%) (2.2%) (3.8%) (3.4%) (100%)
(79%) (89%) (81%) (81%)
(21%) (11%) (19%) (19%)
toring for in¯uenza vaccination has been shown to improve the uptake rates in elderly homes in Wales [17]. Another factor which may explain the dierent uptake rates between England and Wales is the target of 90% coverage by 1997 amongst at-risk groups set by the Welsh Oce NHS Directorate [21]. In our study, the main reason for non-vaccination was refusal by the residents themselves despite vaccine being oered to them. We could not ascertain in detail the exact reasons for refusal by the residents. Previous studies have identi®ed the commonly cited reasons for non-vaccination amongst institutionalised elderly residents which include concerns about vaccine ecacy and its side eects and perception that vaccine is unnecessary [22]. However, anxieties about the vaccine ecacy should not become a barrier to receiving the vaccine as studies in residential elderly population have clearly demonstrated the ecacy of the vaccine [23,24]. Moreover, vaccine prevents up to 50% of hospital related admissions [25] and up to 75% of all cause mortality in elderly high risk groups [26]. In¯uenza vaccine is especially important in the institutionalised setting where evidence suggests that vaccination levels of 70% or more are likely to produce sucient herd immunity to interrupt transmission, thereby substantially reducing the likelihood of an in¯uenza outbreak [22]. Concern about side eects should not be a barrier to vaccination as large randomised placebo controlled trials in the elderly have con®rmed the safety of the vaccine. There is no evidence of higher rates of systemic side eects and local reactions are mild and seldom interfere with daily activities [27]. In the UK, in¯uenza immunisation in the institutional setting is carried out by the GP or the practice nurse in over 75% of cases. Very few nursing homes used `in-house' nursing sta to administer the vaccine [16]. The sta of nursing and old people's homes should share the responsibility with GPs to develop and implement organised and co-ordinated programmes of education and vaccine promotion for the elderly residents. Homes with low immunisation coverage should be targeted. Regular audit [15] and greater use of case registers and computer generated records of elderly people in residential care [28] have been shown to improve the uptake. GPs and primary health
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A. Gupta et al. / Vaccine 18 (2000) 2471±2475
Table 4 Showing the demographics and vaccination uptakes in studies of UK homes Region Leicester South Glamorgan Nottingham South Glamorgana Carmarthenshire a
Year of study Number of homes studied Number of residents 88/89 91/92 92/93 95/96 98/99
11 75 49 30 47
Age (yr)
170 Mean 85 (67±97) 1557 Mean 83 (30±108) 293 (randomly selected) 75% were >75 1007 Mean 85 (38±107) 1399 > 65
Mean vaccine uptake Reference (%) 45 67 40 77 81
14 15 16 17 Present study
The only prospective study.
care teams can play a more active role in the dissemination of bene®ts of vaccine to the elderly residents and their relatives by means of an organised educational campaign. It has been suggested that the delegation of the responsibility of education and vaccination promotion to nurses and the sta of nursing and old people's homes could in¯uence the attitudes of the residents and their relatives towards in¯uenza vaccination positively [29]. Indeed, this group of the population is the easiest to approach and target. Our study suggests that the health professionals are aware of the importance of in¯uenza vaccination and the focus should now be on educational programmes of vaccine promotion in this vulnerable group. Virtually every individual who remains unvaccinated represents a missed opportunity for immunisation. Therefore, increasing the number of vaccinated institutionalised elderly will not only result in cost savings for the NHS in terms of reduced hospitalisation but more signi®cantly, these high risk elderly will bene®t in terms of a decrease in morbidity and mortality [30]. Indeed few, if any, other preventative interventions for the older adult match or exceed these bene®ts [31]. The demographic changes of the next decade will inevitably lead to a growing number of institutionalised elderly people making the results of our study relevant for future in¯uenza control strategies.
Appendix A Groups recommended for in¯uenza vaccination by the Department of Health, UK: Chronic heart disease. Chronic lung disease. Chronic renal failure. Diabetes mellitus. Immunosuppression due to disease or treatment. Long stay residents. Everyone above age 75 yr.
References [1] Nguyen-van-Tam JS, Nicholson KG. In¯uenza deaths in Leicestershire during 1989/90 epidemic: implications for prevention. Epidemiol Infect 1992;108:537±45. [2] Ashley J, Smith T, Dunnell K. Deaths in Great Britain associated with the in¯uenza epidemic of 1989/90. Pop Trends 1991;65:16±20. [3] Arden NH, Patriarca PA, Kendal AP. Experiences in the use and ecacy of inactivated in¯uenza vaccine in nursing homes. In: Kendal AP, Patriarca PA, editors. Options for the control of in¯uenza. New York: Liss, 1986. p. 155±68. [4] Patriarca PA, Weber JA, Parker RA, et al. Ecacy of in¯uenza vaccine in nursing homes. J Am Med Ass 1985;253:1136±69. [5] Saah AJ, Neu®eld R, Rodstein M, et al. In¯uenza vaccine and pneumonia mortality in a nursing home population. Arch Intern Med 1986;146:2353±7. [6] Gross PA, Quinnan GV, Rodstein M, et al. Association of in¯uenza immunization with a reduction in mortality in an elderly population: a prospective study. Arch Intern Med 1988;148:562±5. [7] Strassburg MA, Greenland S, Sorvillo FJ, Leib LE, Habel LA. In¯uenza in the elderly: report of an outbreak and a review of vaccine eectiveness reports. Vaccine 1986;4:38±44. [8] Helliwell BE, Drummond MF. The costs and bene®ts of preventing in¯uenza in Ontario's elderly. Can J Publ Hlth 1988;79:175±80. [9] Mullooly JP, Bennett MD, Hornbrook MC, et al. In¯uenza vaccination programme for elderly persons. Cost eectiveness in a health maintenance organisation. Ann Intern Med 1994;121:947±52. [10] Scot WG, Scott HM. Economic evaluation of vaccination against in¯uenza in New Zealand. Pharmac Econ 1996;9:51±60. [11] Hampson AW, Irving LB. In¯uenza vaccination: cost eective health care for the older adult? J Qual Clin Pract 1997;17(1):3± 11. [12] Nicholson KG, Snacken R, Palache AM. In¯uenza immunisation policies in Europe and U. States. Vaccine 1995;4:365±9. [13] UK Health Department. Immunisation against infectious disease. London: HMSO, 1996. [14] Nicholson KG, Barker DJ, Farquhar A, et al. Acute upper resp tract viral illness and in¯uenza immunisation in homes for the elderly. Epidemiol Infect 1990;105:609±18. [15] Evans MR, Wilkinson EJ. How complete is in¯uenza vaccination coverage? A study in 75 nursing and residential homes for the elderly people. Br J Clin Pract 1995;45:419±21. [16] Warren SS, Nguyen-Van-Tam JS, Pearson JCG, Madely RJ. Practices and policies for in¯uenza immunisation in old people's homes in Nottingham (UK) during 1992±93 season: potential for improvement. J Publ Hlth Med 1995;17:392±6. [17] Evans MR. Monitoring in¯uenza immunisation uptake in nursing homes. Commun Dis Report 1996;6(12):R170 R172.
A. Gupta et al. / Vaccine 18 (2000) 2471±2475 [18] In¯uenza immunisation: extension of current policy. CMO (98): 15/CNO (98): 11. [19] Association for in¯uenza monitoring and surveillance for in¯uenza: residential and nursing care homes policy pack. London: Magellan Medical Communications, 1996. [20] Nguyen-van-Tam J, Nicholson K. In¯uenza immunization: policies and practices of general practitioners in England 1991± 1992. Hlth Trends 1993;25:101±5. [21] Welsh Health Planning Forum. Protocol for investment in health gains in respiratory diseases. Cardi: Welsh Oce NHS Directorate, 1992. [22] Nicholson KG. In¯uenza vaccination and the elderly. Br Med J 1990;301:617±8. [23] Patriarca PA, Weber JA, Parker RA, et al. Risk factors for outbreaks of in¯uenza in nursing homes. Am J Epidemiol 1986;124(1):114±9. [24] Nicholson KG, Barker DJ, Chakravarty P, et al. Immunogenicity of inactivated in¯uenza vaccine in residential homes for elderly people. Age & Ageing 1992;21:182±8. [25] Gross PA, Hermogenes AW, Sacks HS, Lau J, Lewandowski
[26]
[27] [28] [29] [30] [31]
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RA. The ecacy of in¯uenza vaccine in elderly persons: a metaanalysis and review of literature. Ann Intern Med 1995;123:518± 27. Fleming DM, Watson JM, Nicholas S, Smith GE, Swan AV. Study of the eectiveness of in¯uenza vaccine in elderly in the epidemic of 1989±90 using a general practice database. Epidemiology & Infection 1995;115(3):581±9. Goveart TME, Aretz K, Masurel N, et al. Adverse reaction to in¯uenza vaccine in elderly people. Br Med J 1993;307:988±90. Hak E, Van Essen GA, Stalman WA. Improving in¯uenza vaccine coverage among high risk patients: a role for computer supported preventive strategy? Fam Pract 1998;15(2):138±43. Fedson DS. Clinical practice and public policy for in¯uenza and pneumonia vaccination of the elderly. Clin Geriat Med 1992;8:183±99. Nichol KL, Wuorenma J, Von Sternberg T. Bene®ts of in¯uenza vaccine for low, intermediate and high risk senior citizens. Arch Intern Med 1998;158(16):1769±76. Russell LB. Opportunity costs in modern medicine. Hlth Aairs 1992;11:162±9.
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In¯uenza vaccination coverage in old people's home in Carmarthenshire, UK, during the winter of 1998/99 A. Gupta a,*, G. Morris a, P. Thomas b, M. Hasan c a
Prince Phillip Hospital, Llanelli SA14 8QF, UK Carmarthenshire NHS Trust, Prince Phillip Hospital, Llanelli SA14 8QF, UK c University of Wales College of Medicine, Llandough Hospital, Penarth CF64 2XX, UK b
Received 2 June 1999; received in revised form 6 January 2000; accepted 1 February 2000
Abstract A mailed questionnaire survey was undertaken in old people's (nursing and residential) homes in Carmarthenshire, UK to determine the in¯uenza vaccine uptake during the 1998/99 season. Out of the total 60 questionnaires circulated, response was received from 47 homes giving an overall response rate of 78%. Amongst the 1399 residents, 1132 (81%) received in¯uenza vaccine in the winter of 1998/99. Uptake was higher in nursing homes (89%) than in residential homes (79%) or dual registered homes (81%). The most common reason for not receiving in¯uenza vaccination was refusal by the residents themselves, although the vaccine was oered to 99% of residents. This study suggests that strategies to improve communication and provision of educational materials outlining the bene®ts of in¯uenza vaccine to elderly residents and health professionals may help increase the likelihood of vaccine uptake. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: In¯uenza immunisation; Residential and nursing homes; Elderly
1. Introduction In¯uenza remains a major cause of morbidity and mortality. People at greatest risk are the elderly, those with chronic disease and those in residential and long stay homes [1]. During the 1989/90 in¯uenza epidemic, 26,000 in¯uenza related deaths occurred in the UK, with the mortality being highest in older adults living in institutional settings [2]. Outbreaks of in¯uenza in long stay institutions may cause illness in 70% of the residents and up to 22% of those aected develop complications severe enough to result in hospitalisation or death [3]. In¯uenza vaccination prevents in¯uenza related hospitalisation and death amongst nursing home residents [3±6]. A meta-analysis of 16 studies of in¯uenza vac* Corresponding author. Tel.: +0044-01554-756567; fax: +004401554-749527. E-mail address: [email protected] (A. Gupta).
cine in the elderly revealed a 67% reduction in mortality [7]. Moreover, several studies worldwide have clearly demonstrated the cost eectiveness of an in¯uenza immunisation programme in the prevention of in¯uenza and related morbidity in the elderly [8±11]. In the USA, Canada and most European countries, national health policies recommend vaccination of all persons above the age of 65 yr regardless of their health status [12]. In the UK, in¯uenza vaccination is annually recommended for all residents of nursing homes, residential homes and other long stay facilities where rapid spread is likely to follow the introduction of in¯uenza [13] [Appendix A]. Despite the bene®ts of immunisation and despite the guidelines, uptake of vaccination in elderly people in institutional settings remains poor [14±17]. Thus many vaccine preventable deaths and many vaccine preventable hospitalisations from elderly homes continue to occur every year. The recently published UK Department of Health guidelines on in¯uenza immunisation
0264-410X/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 6 4 - 4 1 0 X ( 0 0 ) 0 0 0 4 8 - 7
2472
A. Gupta et al. / Vaccine 18 (2000) 2471±2475
recommend that the vaccine should be oered to all individuals above the age of 75 yr [18]. However, it is not clear whether this has in¯uenced the practice in any way. We undertook this study to measure the in¯uenza vaccine coverage in nursing and residential homes for elderly people in the Carmarthenshire region (UK) during the winter of 1998/99. We are not aware of a similar study in institutionalised elderly residents undertaken in the UK during the winter of 1998/99 since the introduction of October 1998 guidelines by the Department of Health [18]. 2. Methods Ethical approval for the study was obtained from Dyfed Powys Ethics Committee. The Carmarthenshire district in South Wales, UK has a population of 169,000 and there are 60 nursing and residential homes. In December 1998, a postal questionnaire (copies available from the author) and a covering letter was sent along with a stamped addressed envelope to the matron or ocer in charge of each home. Non-responders were reminded by telephone. Information was sought on the in¯uenza vaccination status of all elderly persons resident at the home on 1st January 1999. The questionnaire required information regarding the status of the home (nursing, residential or dual registered), the number of residents present, number vaccinated during the winter of 1998/ 99 and the reasons for those non-vaccinated. The data was entered in an IBM personal computer for processing and analysis. Responses were summarised and percentage frequencies were determined for the response. 3. Results Of the 60 questionnaires sent out, 47 (78.3%) were completed and returned. The information received cov-
Table 1 In¯uenza vaccination coverage in the 47 homes which responded Percentage of residents immunised
Number (%) of homes with uptake rate
< 50 50±59 60±69 70±79 80±89 90±99 100 Total
5 5 4 3 10 13 7 47
(10.6%) (10.6%) (8.5%) (6.4%) (21.3%) (27.7%) (14.9%) (100%)
ered 1399 residents ranging from 7 to 107 residents per home. Of the 1399 residents, 1132 residents received in¯uenza vaccination during the winter of 1998/99 (81% uptake). Table 1 shows the coverage of in¯uenza vaccination in homes studied. The uptake rate varied from seven homes achieving 100% immunisation coverage to one home with the lowest rate of 38%. Five homes had below 50% vaccination uptake. Table 2 illustrates the percentage of residents vaccinated according to the categories of homes. Of the four homes registered as nursing homes, in¯uenza vaccine was received by 136 out of 153 residents (89% uptake). Of the 33 residential homes, 614 of 774 residents were vaccinated (79%). Amongst dual registered homes, vaccination coverage was 81% in 382 of the 472 residents. Table 3 illustrates the reasons for non-vaccination. The most common reason for non-vaccination was refusal by the residents themselves in 157 (59%) residents. It is noted that only <1% of the study population were not oered vaccine. The pattern of reasons for not vaccinating/being vaccinated were the same for homes in the lower range of uptake scale and for institutions with high uptake rates and the results were statistically non-conclusive. 4. Discussion This study demonstrates a mean in¯uenza vaccine uptake of 81% amongst 1399 elderly residents of 47 nursing and residential homes in Carmarthenshire, UK, during the winter of 1998/99. Previous UK studies have shown an in¯uenza vaccine uptake of 45% in Leicestershire in 1988/89 [14], 67% in South Glamorgan in 1991/92 [15], 40% in Nottingham in 1992/93 [16] and 77% in South Glamorgan in 1995 [17] amongst the residents of old people's homes. It appears that in recent years, there is a trend towards improved vaccination coverage in institutionalised people. It is not exactly clear from our study what led to such a high vaccine uptake. We feel that the better uptake could be related to an improved awareness of the bene®ts of in¯uenza vaccination by the primary care sta and residents of these homes. We believe that it is too early for the recent UK guidelines [18] to have its impact on vaccination coverage. Table 4 shows the demographics of residents in previous UK studies examining the in¯uenza vaccination coverage. The population groups are non-homogenous in terms of age and size of the populations and this could account for the dierent uptake rates. However, in South Glamorgan studies [15,17] there was no relation observed between in¯uenza immunisation in dierent homes and the age, sex, number of residents,
A. Gupta et al. / Vaccine 18 (2000) 2471±2475
2473
Table 2 Vaccination status according to the type of home Type of home
Number of residents
Number (%) vaccinated
Number (%) not vaccinated
Residential Nursing Dual registered Total
774 153 472 1399
614 136 382 1132
160 17 90 267
length of residence, whether immunised at home or at the GP surgery. We have demonstrated a slightly better uptake in nursing homes than in residential homes and this was also noted in a previous study [15]. We did not ascertain the underlying illness or the medical risk factors associated with in¯uenza vaccination because in¯uenza immunisation is recommended for all residents in nursing and residential homes regardless of their age and health status [13]. Appendix A outlines the groups recommended for in¯uenza vaccination by the Department of Health, UK, therefore risk factors should not in¯uence the decision to vaccinate. Moreover, previous studies have reported for all residents to have one or more indications for vaccination and additional risk factors were present in more than 70% of residents [14]. All homes in the UK are subject to regular inspections for registration purposes under the Registered Homes Act of 1984. This ensures that the homes keep a proper record of vaccination coverage. The Association for In¯uenza Monitoring and Surveillance has issued a policy pack for nursing and residential homes, which encourages sta to promote in¯uenza immunisation of residents and keep proper immunisation records [19]. However, there is a large variability in policies for promoting in¯uenza vaccination in old people's homes throughout England and Wales. In the Nottingham study, 52% of the homes claimed to operate a policy for in¯uenza immunisation but only 12% had a written down policy and none set targets for vaccine uptake [16]. Studies have suggested that the presence of a policy for in¯uenza vaccination by the general practitioners is an important factor which determines the vaccine uptake [20]. Prospective moniTable 3 Showing the reasons for non-vaccination Reason for non-vaccination
Number (%) of residents
Refused by resident Refused by relative Unwell De®nite allergy in past Never oered Unknown Total
157 34 51 6 10 9 267
(58.8%) (12.7%) (19.1%) (2.2%) (3.8%) (3.4%) (100%)
(79%) (89%) (81%) (81%)
(21%) (11%) (19%) (19%)
toring for in¯uenza vaccination has been shown to improve the uptake rates in elderly homes in Wales [17]. Another factor which may explain the dierent uptake rates between England and Wales is the target of 90% coverage by 1997 amongst at-risk groups set by the Welsh Oce NHS Directorate [21]. In our study, the main reason for non-vaccination was refusal by the residents themselves despite vaccine being oered to them. We could not ascertain in detail the exact reasons for refusal by the residents. Previous studies have identi®ed the commonly cited reasons for non-vaccination amongst institutionalised elderly residents which include concerns about vaccine ecacy and its side eects and perception that vaccine is unnecessary [22]. However, anxieties about the vaccine ecacy should not become a barrier to receiving the vaccine as studies in residential elderly population have clearly demonstrated the ecacy of the vaccine [23,24]. Moreover, vaccine prevents up to 50% of hospital related admissions [25] and up to 75% of all cause mortality in elderly high risk groups [26]. In¯uenza vaccine is especially important in the institutionalised setting where evidence suggests that vaccination levels of 70% or more are likely to produce sucient herd immunity to interrupt transmission, thereby substantially reducing the likelihood of an in¯uenza outbreak [22]. Concern about side eects should not be a barrier to vaccination as large randomised placebo controlled trials in the elderly have con®rmed the safety of the vaccine. There is no evidence of higher rates of systemic side eects and local reactions are mild and seldom interfere with daily activities [27]. In the UK, in¯uenza immunisation in the institutional setting is carried out by the GP or the practice nurse in over 75% of cases. Very few nursing homes used `in-house' nursing sta to administer the vaccine [16]. The sta of nursing and old people's homes should share the responsibility with GPs to develop and implement organised and co-ordinated programmes of education and vaccine promotion for the elderly residents. Homes with low immunisation coverage should be targeted. Regular audit [15] and greater use of case registers and computer generated records of elderly people in residential care [28] have been shown to improve the uptake. GPs and primary health
2474
A. Gupta et al. / Vaccine 18 (2000) 2471±2475
Table 4 Showing the demographics and vaccination uptakes in studies of UK homes Region Leicester South Glamorgan Nottingham South Glamorgana Carmarthenshire a
Year of study Number of homes studied Number of residents 88/89 91/92 92/93 95/96 98/99
11 75 49 30 47
Age (yr)
170 Mean 85 (67±97) 1557 Mean 83 (30±108) 293 (randomly selected) 75% were >75 1007 Mean 85 (38±107) 1399 > 65
Mean vaccine uptake Reference (%) 45 67 40 77 81
14 15 16 17 Present study
The only prospective study.
care teams can play a more active role in the dissemination of bene®ts of vaccine to the elderly residents and their relatives by means of an organised educational campaign. It has been suggested that the delegation of the responsibility of education and vaccination promotion to nurses and the sta of nursing and old people's homes could in¯uence the attitudes of the residents and their relatives towards in¯uenza vaccination positively [29]. Indeed, this group of the population is the easiest to approach and target. Our study suggests that the health professionals are aware of the importance of in¯uenza vaccination and the focus should now be on educational programmes of vaccine promotion in this vulnerable group. Virtually every individual who remains unvaccinated represents a missed opportunity for immunisation. Therefore, increasing the number of vaccinated institutionalised elderly will not only result in cost savings for the NHS in terms of reduced hospitalisation but more signi®cantly, these high risk elderly will bene®t in terms of a decrease in morbidity and mortality [30]. Indeed few, if any, other preventative interventions for the older adult match or exceed these bene®ts [31]. The demographic changes of the next decade will inevitably lead to a growing number of institutionalised elderly people making the results of our study relevant for future in¯uenza control strategies.
Appendix A Groups recommended for in¯uenza vaccination by the Department of Health, UK: Chronic heart disease. Chronic lung disease. Chronic renal failure. Diabetes mellitus. Immunosuppression due to disease or treatment. Long stay residents. Everyone above age 75 yr.
References [1] Nguyen-van-Tam JS, Nicholson KG. In¯uenza deaths in Leicestershire during 1989/90 epidemic: implications for prevention. Epidemiol Infect 1992;108:537±45. [2] Ashley J, Smith T, Dunnell K. Deaths in Great Britain associated with the in¯uenza epidemic of 1989/90. Pop Trends 1991;65:16±20. [3] Arden NH, Patriarca PA, Kendal AP. Experiences in the use and ecacy of inactivated in¯uenza vaccine in nursing homes. In: Kendal AP, Patriarca PA, editors. Options for the control of in¯uenza. New York: Liss, 1986. p. 155±68. [4] Patriarca PA, Weber JA, Parker RA, et al. Ecacy of in¯uenza vaccine in nursing homes. J Am Med Ass 1985;253:1136±69. [5] Saah AJ, Neu®eld R, Rodstein M, et al. In¯uenza vaccine and pneumonia mortality in a nursing home population. Arch Intern Med 1986;146:2353±7. [6] Gross PA, Quinnan GV, Rodstein M, et al. Association of in¯uenza immunization with a reduction in mortality in an elderly population: a prospective study. Arch Intern Med 1988;148:562±5. [7] Strassburg MA, Greenland S, Sorvillo FJ, Leib LE, Habel LA. In¯uenza in the elderly: report of an outbreak and a review of vaccine eectiveness reports. Vaccine 1986;4:38±44. [8] Helliwell BE, Drummond MF. The costs and bene®ts of preventing in¯uenza in Ontario's elderly. Can J Publ Hlth 1988;79:175±80. [9] Mullooly JP, Bennett MD, Hornbrook MC, et al. In¯uenza vaccination programme for elderly persons. Cost eectiveness in a health maintenance organisation. Ann Intern Med 1994;121:947±52. [10] Scot WG, Scott HM. Economic evaluation of vaccination against in¯uenza in New Zealand. Pharmac Econ 1996;9:51±60. [11] Hampson AW, Irving LB. In¯uenza vaccination: cost eective health care for the older adult? J Qual Clin Pract 1997;17(1):3± 11. [12] Nicholson KG, Snacken R, Palache AM. In¯uenza immunisation policies in Europe and U. States. Vaccine 1995;4:365±9. [13] UK Health Department. Immunisation against infectious disease. London: HMSO, 1996. [14] Nicholson KG, Barker DJ, Farquhar A, et al. Acute upper resp tract viral illness and in¯uenza immunisation in homes for the elderly. Epidemiol Infect 1990;105:609±18. [15] Evans MR, Wilkinson EJ. How complete is in¯uenza vaccination coverage? A study in 75 nursing and residential homes for the elderly people. Br J Clin Pract 1995;45:419±21. [16] Warren SS, Nguyen-Van-Tam JS, Pearson JCG, Madely RJ. Practices and policies for in¯uenza immunisation in old people's homes in Nottingham (UK) during 1992±93 season: potential for improvement. J Publ Hlth Med 1995;17:392±6. [17] Evans MR. Monitoring in¯uenza immunisation uptake in nursing homes. Commun Dis Report 1996;6(12):R170 R172.
A. Gupta et al. / Vaccine 18 (2000) 2471±2475 [18] In¯uenza immunisation: extension of current policy. CMO (98): 15/CNO (98): 11. [19] Association for in¯uenza monitoring and surveillance for in¯uenza: residential and nursing care homes policy pack. London: Magellan Medical Communications, 1996. [20] Nguyen-van-Tam J, Nicholson K. In¯uenza immunization: policies and practices of general practitioners in England 1991± 1992. Hlth Trends 1993;25:101±5. [21] Welsh Health Planning Forum. Protocol for investment in health gains in respiratory diseases. Cardi: Welsh Oce NHS Directorate, 1992. [22] Nicholson KG. In¯uenza vaccination and the elderly. Br Med J 1990;301:617±8. [23] Patriarca PA, Weber JA, Parker RA, et al. Risk factors for outbreaks of in¯uenza in nursing homes. Am J Epidemiol 1986;124(1):114±9. [24] Nicholson KG, Barker DJ, Chakravarty P, et al. Immunogenicity of inactivated in¯uenza vaccine in residential homes for elderly people. Age & Ageing 1992;21:182±8. [25] Gross PA, Hermogenes AW, Sacks HS, Lau J, Lewandowski
[26]
[27] [28] [29] [30] [31]
2475
RA. The ecacy of in¯uenza vaccine in elderly persons: a metaanalysis and review of literature. Ann Intern Med 1995;123:518± 27. Fleming DM, Watson JM, Nicholas S, Smith GE, Swan AV. Study of the eectiveness of in¯uenza vaccine in elderly in the epidemic of 1989±90 using a general practice database. Epidemiology & Infection 1995;115(3):581±9. Goveart TME, Aretz K, Masurel N, et al. Adverse reaction to in¯uenza vaccine in elderly people. Br Med J 1993;307:988±90. Hak E, Van Essen GA, Stalman WA. Improving in¯uenza vaccine coverage among high risk patients: a role for computer supported preventive strategy? Fam Pract 1998;15(2):138±43. Fedson DS. Clinical practice and public policy for in¯uenza and pneumonia vaccination of the elderly. Clin Geriat Med 1992;8:183±99. Nichol KL, Wuorenma J, Von Sternberg T. Bene®ts of in¯uenza vaccine for low, intermediate and high risk senior citizens. Arch Intern Med 1998;158(16):1769±76. Russell LB. Opportunity costs in modern medicine. Hlth Aairs 1992;11:162±9.