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Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination
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Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination Coralie Giese a,b , Jolita Mereckiene b , Kostas Danis a , Joan O’Donnell b , Darina O’Flanagan b , Suzanne Cotter b,∗ a b
European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden HSE Health Protection Surveillance Centre, Dublin, Ireland
a r t i c l e
i n f o
Article history: Received 31 December 2015 Received in revised form 10 May 2016 Accepted 11 May 2016 Available online xxx Keywords: Immunisation Influenza Pneumococcal Vaccination At-risk Elderly
a b s t r a c t The World Health Organization (WHO), and European Agencies recommend influenza vaccination for individuals at-risk due to age (≥65 years), underlying diseases, pregnancy and for health care workers (HCWs) in Europe. Pneumococcal vaccine is recommended for those at-risk of pneumococcal disease. In Ireland, vaccination uptake among at-risk adults is not routinely available. In 2013, we conducted a national survey among Irish residents ≥18 years of age, to estimate size and vaccination coverage of at-risk groups, and identify predictive factors for influenza vaccination. We used computer assisted telephone interviews to collect self-reported information on health, vaccination status, attitudes towards vaccination. We calculated prevalence and prevalence ratios (PR) using binomial regression. Overall, 1770 individuals participated. For influenza, among those aged 18–64 years, 22% (325/1485) [95%CI: 17%–20%] were at-risk; 28% [95%CI: 23%–33%] were vaccinated. Among those aged ≥65 years, 60% [95%CI: 54%–66%] were vaccinated. Influenza vaccine uptake among HCWs was 28% [95%CI: 21%–35%]. For pneumococcal disease, among those aged 18–64 years, 18% [95%CI: 16%–20%] were at-risk; 16% [95%CI: 12%–21%] reported ever-vaccination; among those aged ≥65 years, 36% [95%CI: 30%–42%] reported evervaccination. Main reasons for not receiving influenza vaccine were perceptions of not being at-risk, or not thinking of it; and among HCWs thinking that vaccination was not necessary or they were not atrisk. At-risk individuals were more likely to be vaccinated if their doctor had recommended it (PR 3.2; [95%CI: 2.4%-4.4%]) or they had access to free medical care or free vaccination services (PR 2.0; [95%CI: 1.5%-2.8%]). Vaccination coverage for both influenza and pneumococcal vaccines in at-risk individuals aged 18–64 years was very low. Influenza vaccination coverage among individuals ≥65 years was moderate. Influenza vaccination status was associated with GP vaccination recommendation and free access to vaccination services. Doctors should identify and recommend vaccination to at-risk patients to improve uptake. © 2016 Published by Elsevier Ltd.
1. Introduction Influenza is a highly infectious disease which has significant morbidity and mortality. Invasive streptococcus pneumoniae can cause serious disease or death, particularly for at-risk groups [1,2]. Both diseases are potentially vaccine preventable and there is good
∗ Corresponding author at: Health Services Executive Health Protection Surveillance Centre (HSE-HPSC), 25–27 Middle Gardiner St., Dublin 1, Ireland. Tel.: +353 1 876 5300; fax: +353 1 8561299. E-mail address: [email protected] (S. Cotter).
international evidence of which groups benefit from vaccination with either vaccine [1,2]. Most high and middle-income countries have vaccination recommendations together with funding mechanisms to encourage vaccination, particularly for influenza [3]. International studies have identified a wide range of factors associated with vaccine acceptance, including social and cultural beliefs, access to services, and public policies. Despite strong international and national vaccination recommendations uptake among risk groups there has been little progress made in Ireland in recent years [3]. The European Commission (EC) recommends that all EU countries monitor seasonal influenza vaccination coverage in high risk groups. The World
http://dx.doi.org/10.1016/j.vaccine.2016.05.028 0264-410X/© 2016 Published by Elsevier Ltd.
Please cite this article in press as: Giese C, et al. Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination. Vaccine (2016), http://dx.doi.org/10.1016/j.vaccine.2016.05.028
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Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) have defined risk groups for influenza as persons at higher risk of having an adverse outcome (e.g. severe disease or death) from infection, including individuals aged ≥65 years, those with specified medical conditions (including pregnancy), and health care workers (HCWs) [4,5]. Invasive pneumococcal disease is a particular risk for the very young, the elderly and those with chronic medical conditions [6]. 1.1. At-risk populations and vaccination programme in Ireland In Ireland, the National Immunisation Advisory Committee (NIAC) makes vaccine recommendations for the population. Risk groups identified are similar to those identified internationally [2,6,7]. The Health Services Executive of Ireland (HSE) supports the influenza and pneumococcal vaccination programme for those in at-risk groups by providing free vaccines. Vaccine administration fees may apply for individuals ineligible for free access to primary care services (General Medical Service [GMS] medical card or GP visit [GPV] card) [8]. Eligibility for free primary care services is usually income dependent. HCWs are entitled to free vaccine administration (occupational health services). The HSE-National Immunization Office (HSE-NIO) procures and distributes influenza vaccine to health care facilities (hospitals, long-term care facilities, GP practices and community pharmacies). Pneumococcal vaccines are provided to GP sites. HSE-NIO promotes these vaccines using a variety of media (radio or television, leaflets, posters). 1.2. Influenza and pneumococcal vaccine uptake in at-risk populations In Ireland, there is no comprehensive information system with which to estimate uptake of influenza or pneumococcal vaccines among at-risk adults. In an effort to fill this gap the Health Protection Surveillance Centre (HPSC) uses administrative data (payment claims from GP or pharmacies) to estimate uptake among elderly entitled to free vaccination. For HCWs, surveys of health care facilities have been done since 2011 [9]. Previous work done by HSE-NIO in 2011 identified potential barriers to influenza vaccination (including low risk perception, concerns about vaccine side effects and costs of vaccine administration) [10]. Between August and October 2013, we undertook a survey from a sample of the Irish adult population to: estimate the proportion of community-based adults who had risk conditions, or were HCWs, for whom influenza or pneumococcal vaccination was recommended; estimate vaccination coverage among those groups; and identify factors associated with seasonal influenza vaccination status during the influenza season 2012–2013.
We estimated the sample size Open Epi, version 3 (http://www. openepi.com/v37/SampleSize/SSPropor.htm). Assuming that 11% of those with underlying conditions belong to the risk groups for influenza, [11] a sample size of 1700 persons was required for a desired precision ±1.5%. Random digital dialling was applied for generating telephone numbers for landline and mobile phones. We excluded persons living in institutional settings and those unable to complete the telephone interview due to language or speech difficulties. A market research company specialising in CATI carried out the survey and recruited participants.
2.3. Data collection We developed a standardised questionnaire similar to those previously used (2006, 2010). We sought information on respondent’s age, gender, residential area according to HSE administrative region; vaccination status (seasonal influenza, pneumococcal vaccines), reasons for getting/not getting influenza vaccines, medical risk conditions (diagnosed by doctor), or occupational risk. Trained interviewers administered questionnaires and entered data onto the database at time of interview. The interviews were done between August 28th and October 14th, 2013 during days and evenings. One adult person per household was interviewed. If there were two eligible adult persons who consented to being interviewed, the person who fulfilled the age group and gender quota or with the next birthday was interviewed.
2.4. Operational definitions For the purpose of this study we defined risk groups for whom influenza vaccine was recommended as those who were aged 65 years or more; participants who reported having any underlying medical conditions which were identified by using simple questions asked to each participant if they had any of the following conditions for which influenza vaccine is indicated; asthma, any chronic lung disease, any condition of nervous system that may affect respiratory function; any chronic illness requiring medical follow up or hospitalisation (e.g. diabetes, kidney disease, inherited blood disorder, metabolic diseases or cancer); on any medication that may affect immune system; having had a heart attack or stroke; chronic heart disease; morbid obesity or being pregnant during the previous influenza season [7]. We defined individuals as being atrisk for pneumococcal disease if they were aged 65 years and over or reported a medical condition for which pneumococcal vaccination was indicated (asthma, condition of nervous system that may affect respiratory function, chronic illness requiring medical follow up or hospitalisation, chronic lung disease, being on medication that may affect immune system, or reported previous heart attack or stroke).
2. Method 2.1. Study design and population We conducted a national telephone survey among adults aged 18 years and over, residing in Ireland (non-institutionalised), using computer assisted telephone interviews (CATI). This survey followed similar methodology to previous national telephone surveys in 2006 [11] and in 2010 [12]. 2.2. Sampling methods We used quota sampling methods. Quota sampling reflected the demographics based on age, sex and region of residence of the Irish population.
2.5. Data analysis We calculated frequencies and proportions of all categorical variables. We calculated prevalence ratios (PR) and 95% confidence intervals (95%CI) using binomial regression.
2.6. Ethical issues Oral informed consent was obtained from all respondents. Questionnaires did not have personal identification details. All information was confidential and protected by the Irish Data Protection Act 2003. Ethics approval was granted from the Royal College of Physicians of Ireland for this study.
Please cite this article in press as: Giese C, et al. Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination. Vaccine (2016), http://dx.doi.org/10.1016/j.vaccine.2016.05.028
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Table 1 Comparison of respondents with 2011 census adult population in terms of age group, gender, and region. Adult vaccine uptake survey, Ireland, August 2013. CSOa data (2011 census)
Survey
p value
n
(%)
95%CI
Population
(%)
Age group 18–24 25–34 35–49 50–64 65+ Total
214 340 516 415 285 1770
12 19 29 23 16 100
11–14 17–21 27–31 22–26 14–18 –
411,153 755,067 1,000,258 737,694 535,393 3,439,565
12 22 29 21 16 100
0.045
Gender Male Female Total
863 907 1770
49 51 100
46–51 49–54 –
1,684,917 1,754,648 3,439,565
49 51 100
0.847
HSE region HSE-E HSE-M HSE-MW HSE-NE HSE-NW HSE-S HSE-SE HSE-W Total
768 67 191 243 76 158 137 130 1770
43 3.8 11 14 4.3 8.9 7.7 7.3 100
41–46 2.9–4.8 9.4–12 12–15 3.4–5.3 7.6–10 6.5–9.1 6.2–8.7 –
1,236,870 204,684 284,338 317,781 191,004 501,146 368,170 335,572 3,439,565
36 6 8.3 9.2 5.6 15 11 9.8 100
<0.001
a
Central Statistics Office.
3. Results 3.1. At-risk population in Ireland Of 18,238 valid telephone contacts made, we interviewed 1770 (10%) persons. Compared with 2011 census data, those in the 25–34 years age group were under-represented, while those in 50–64 year age group were over-represented; those in the HSE Eastern region
(HSE-E), which includes the greater Dublin metropolitan area were over-represented (Table 1). Among all respondents, 35% (610/1770) [95%CI: 32%–37%] were at-risk for influenza due to age or medical conditions; 16% (285/1770) [95%CI: 14%–18%] were aged ≥65 years and were therefore at-risk for both influenza and pneumococcal diseases (Table 2). Among those aged 18–64 years, 22% (325/1485) [95%CI: 17%–20%] were at-risk for influenza due to underlying medical
Table 2 Seasonal influenza vaccine uptake since September 1st 2012 (season 2012–13) and pneumococcal vaccine (ever) uptake, adult vaccine uptake survey, Ireland, August 2013.
Overalla Sex Female Male Age group 18–24 25–34 35–49 50–64 65+ Health care worker (HCW) Persons over 65 yearsb Persons aged 18–64 with medical conditionsc (average for at least one medical condition) Asthma Chronic heart disease Heart attack or stroke Under medication that may affect immune system Lung disease Chronic illness requiring medical follow up or hospitalisation Condition of nervous system affecting respiratory function Pregnantd Obesity a b c d
Vaccine uptake for seasonal influenza
Vaccine uptake for pneumococcal disease
Proportion population %
Vaccinated
Total
%
95%CI (%)
Vaccinated
Total
%
95%CI (%)
100
370
1770
21
19 to 23
185
1695
11
9.4 to 12
51 49
178 192
904 858
20 22
17 to 22 20 to 25
94 91
878 817
11 11
8.7 to 12 9.0 to 13
12 19 29 23 16 9.3 16 22
18 29 61 93 169 46 169 90
214 340 516 415 285 164 282 324
8 9 12 22 59 28 60 28
5.1 to 13 5.8 to 12 9.1 to 15 18 to 27 53 to 65 21 to 35 54 to 66 23 to 33
23 16 18 30 98 – 98 41
198 325 499 402 271 – 271 250
12 5 4 7 36 – 36 16
7.2 to 16 2.6 to 7 2.0 to 5 4.9 to 10 30.4 to 42 – 30 to 42 12 to 21
8.6 1.9 1.4 3.7
29 12 9 22
126 28 21 197
23 43 43 40
16 to 31 23 to 64 20 to 66 27 to 53
19 6 – 12
119 28 – 52
16 21 – 23
9.3 to 23 5.2 to 38 – 11 to 35
0.9 7.7
5 45
14 114
36 40
7.0 to 64 30 to 49
4 23
14 106
29 22
1.5 to 56 14 to 30
1.1
3
16
19
−2.7 to 40
2
15
13
−6.2 to 33
7.4 1.8
10 8
45 26
22 31
9.6 to 35 12 to 50
– –
– –
– –
– –
75 missing values on pneumococcal vaccination status. 3 missing values on influenza vaccination status and 14 missing values on pneumococcal vaccination status. 1 missing value on influenza vaccination status and 14 missing values on pneumococcal vaccination status. restricted to women 18–54 pregnant between September 2012–October 2013.
Please cite this article in press as: Giese C, et al. Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination. Vaccine (2016), http://dx.doi.org/10.1016/j.vaccine.2016.05.028
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Table 3 Reported reasonsa for not getting seasonal influenza vaccines among adults by at-risk groups for influenza season 2012–13, Ireland, August 2012 (n = 1392). All respondents
Perceptions of low risk Not needing influenza vaccination I Don’t get the flu I am not at riskc I don”t like injections/going to the doctor It doesn”t work/is ineffective I may get the flu from it, I fear the side effects I got the flu from it last time, it has side effects on me Problems with awareness/access/affordability Did not think about it, forgot to ask about it this year No time, I didn’t get around to it Didn’t know the flu injection was available to me Wasn’t offered the flu injection by my family doctor/GP Other reason No reason a b c
18–64 with underlying medical conditions
Over 65
HCWsb
n
%
95%CI (%)
n
%
95%CI (%)
n
%
95%CI (%)
n
%
95%CI (%)
397 277 162 42 34 31 28
29 20 12 3.0 2.4 2.2 2.0
26–31 18–22 10–13 2.2–4.1 1.7–3.4 1.5–3.2 1.3–2.9
58 32 27 5 13 9 5
25 14 12 2.1 5.6 3.9 2.1
19–31 9.5–19 7.7–16 0.7–4.9 3.0–9.3 1.8–7.2 0.7–4.9
26 17 3 8 3 3 4
23 15 2.7 7.1 2.7 2.7 3.5
16–32 9.0–23 0.6–7.6 3.1–14 0.6–7.6 0.6–7.6 1.0–8.8
39 17 14 2 3 3 5
33 14 12 1.7 2.5 2.5 4.2
25–42 8.6–22 6.6–19 0.2–6.0 0.5–7.2 0.5–7.2 1.4–9.6
150
11
9.2–13
29
12
8.5–17
22
20
13–28
5
4.2
1.4–9.6
62 30
4.5 2.2
3.4–5.7 1.5–3.1
16 4
6.8 1.7
4.0–11 0.5–4.3
4 –
3.5 –
1.0–8.8 –
7 1
5.9 0.9
2.4–12 0.02–4.6
25
1.8
1.2–2.6
4
1.7
0.5–4.3
6
5.3
2.0–11
4
3.4
0.9–8.5
55
4.0
3.0–5.1
7
3.0
1.2–6.1
5
4.4
1.5–10
5
4.2
1.4–9.6
One (first) reason given per participant when asked for reason for non-vaccination. Health care worker. Only for people with pre-existing health conditions, elderly or pregnant.
conditions. Of all participants, 164 (9.3%) [95%CI: 0.8%–11%] were HCWs; of whom 36 (22%) also had a medical or age related risk for influenza (Table 2). Regarding pneumococcal disease, 31% (549/1770) [95%CI: 29%–33%] of all respondents reported being at-risk, including 18% (264/1485) [95%CI: 13%–17%] of those aged 18–64 years.
3.2. Influenza and pneumococcal vaccine uptake in at-risk populations Among those in the 18–64 year age group for whom seasonal influenza vaccine was recommended, 28%(90/324) [95%CI: 23%–33%] were vaccinated; in those aged ≥65 years, 60%(169/282) [95%CI: 54%–66%] were vaccinated (Table 2). Overall vaccine uptake in HCWs was 28% (46/164) [95%CI: 19%–23%] (Table 2); but varied by risk group and age. Vaccine uptake for HCWs with no medical or age related risk was 24% (31/129) [95%CI: 17%–32%]; 75% [95%CI: 19%–99%] among HCWs aged ≥65 years; and 39% (12/31) [95%CI: 22%–58%] among those with medical conditions. Among those for whom pneumococcal vaccine was recommended; 16% (41/250) [95%CI: 12%–21%] of those aged 18–64 years reported ever being vaccinated; and 36% (98/271) [95%CI: 30%–42%] of those aged ≥65 years (Table 2). 3.3. Barriers and predictors for vaccination 3.3.1. Reported reasons for not being vaccinated Amongst those aged 18–64 years for whom seasonal influenza vaccination was indicated, reasons for non-vaccination included: vaccination was not necessary for them (25% [95%CI: 19%–31%]); rarely getting influenza (14% [95%CI: 9.5%–19%]); not thinking about it (12% [95%CI: 8.5%–17%]); or not considering themselves at-risk (12%[95%CI: 7.7%–16%]) (Table 3). Similar reasons were reported amongst those aged 65 years and over who were not vaccinated. The main reasons for non-vaccination reported by HCWs were that vaccination was not necessary for them (33% [95%CI: 25%–42%]), they rarely get influenza (14% [95%CI: 8.6%–22%]) or they considered themselves not at- risk (12% [95%CI: 6.6%–19%]).
3.3.2. Factors associated with vaccination Overall, individuals belonging to at-risk groups for influenza were more likely to be vaccinated if their doctor had recommended it even when they did not have a medical card/GP visit card (PR 3.2; [95%CI: 2.4–4.4]; p < 0.001). If they had a medical card/GP visit card but vaccination hadn’t been recommended by their doctor (PR 2.0; [95%CI; 1.5–2.8]; p < 0.001) (data not shown in table), they were still likely to be vaccinated. Additionally, 36% of all those in at risk groups reported that they got the vaccine because their doctor recommended it.
4. Discussion The survey provided information on vaccination uptake for those at-risk population groups for whom there is little available data. For influenza, overall vaccine uptake among at-risk populations was below the EU/WHO recommended target of 75%. For pneumococcal vaccination, vaccination uptake, as found in this study, was poor despite long standing recommendations in Ireland.
4.1. At-risk population in Ireland In this study, the estimated proportion of individuals aged 18–64 with underlying medical conditions for influenza (22%) was higher than previously reported prevalence estimates from the UK and ECDC but higher than that reported in the 2006 national telephone survey (11%) [11]. However, the criteria for medical or underlying conditions in the UK study excluded a number of risk factors that were included in our survey, such as obesity and other nonspecified chronic medical conditions that may require medical follow up [5]. Pregnancy was also included in our study as a risk condition. Our findings are compatible with date obtained in the 2011 national census when between 23% and 42% of individuals aged 18–64 years reported having a doctor diagnosed medical condition, most of which necessitated long term follow-up [13]. These differences would we believe account for the differences found.
Please cite this article in press as: Giese C, et al. Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination. Vaccine (2016), http://dx.doi.org/10.1016/j.vaccine.2016.05.028
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4.2. Influenza and pneumococcal vaccine uptake in those populations 4.2.1. Influenza vaccination Influenza vaccine uptake among individuals aged 18–64 with underlying medical conditions, in those aged ≥65 years and in HCWs remained far below the EU target of 75% by 2014–15 for all at-risk populations [6]. Among persons aged 18–64 years with underlying medical conditions, estimated vaccine uptake for seasonal influenza vaccine in this study, was similar to the 2006 (27%) and 2010 (29%) national telephone surveys [11,12]. For individuals aged 65 years and over, our estimated influenza vaccine uptake was similar to what was reported by the General Medical Card (GMS) for the same season [14]. This is less than that reported in the 2006 and 2010 surveys (69% and 64% respectively) but the difference is not statistically significant. It is not clear whether this slight decrease in uptake is due to concerns related to the vaccine safety, highlighted after the pandemic influenza vaccine, or other unidentified factors. Several studies in France, Germany and Spain have indicated that influenza vaccination coverage in targeted populations decreased in post-pandemic seasons [15–17]. In Spain, vaccine coverage decreased to 58% in 2011–12, compared with 64% and 67% in 2003 and 2006, respectively [18]. Our estimated vaccine uptake among HCWs for seasonal influenza vaccine in 2013 was similar to that estimated in a similar survey in 2010 (27%) and although greater than that reported in 2006 (20%) survey was not statistically significant [11]. Uptake reported in this survey was higher than that reported from the National Survey of hospitals and long-term care facilities for the 2012–13 season where average uptake among HCWs working in hospitals and long term care facilities was estimated at 24% and 23% respectively [9]. The higher self-reported uptake from this telephone survey may reflect that more HCWs are vaccinated outside the hospital and long term care facility occupational health settings and their vaccination records are not reflected in management figures. As HCWs are strongly recommended vaccination in Ireland the reported uptake rates are particularly concerning and highlights the need for implementation of specific strategies and programmes for this priority group if targets are to be achieved [4,6]. 4.2.2. Pneumococcal vaccination Since the initial national telephone survey in 2006 and in the 2010 and 2013 survey (as reported in this paper) reported uptake of pneumococcal vaccine has increased among those with underlying medical conditions in the 18–64 years age group (11%, 12% and 14%, respectively). Pneumococcal vaccine uptake in the older population was more than double that reported in the younger at risk groups, with reported uptake in the 65 years and older age groups increasing with each subsequent survey (27%, 33% and 36% in 2005, 2010 and 2013, respectively). Despite this improvement, the overall low uptake still highlights that at-risk populations are not getting the vaccine. Other developed countries such as the USA have achieved higher coverage for at-risk groups, with researchers from the US reporting in 2013 uptakes of (21%) in the 19–64 years at-risk and (60%) among adults aged 65 years or older [19]. We did not investigate the reasons for not being vaccinated with pneumococcal vaccine in this study. A Canadian study among adults 65 years of age or older identified a positive correlation between vaccination recommendations from a HCW with vaccination status [20]. 4.3. Attitudes towards and predictors of influenza vaccination The most common reason reported by at-risk participants who were unvaccinated for influenza was a perception of being at low
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risk. Similar findings were reported in the 2010 telephone survey [12] and HSE-NIO study in2011 [10]. This indicates limited awareness of the benefits of vaccination and of the seriousness of the infection among the at-risk population, and especially among HCWs. Access to free vaccine administration was associated with influenza vaccination status. Even for HCWs, free access to vaccines has been found to be associated with improving vaccination uptake. One Australian study found that vaccine uptake was higher in GPs working at practices that provided free vaccine for influenza (85% versus 58%) and that paying for vaccine was identified as a barrier by 25% of respondents [21]. We found in this study that some individuals from the targeted population, and especially those aged 65 years and over, may forget and not think about getting vaccinated, highlighting the importance of health care provider reminder/recommendation. Other studies have suggested that age-based strategies to increase vaccine uptake were efficient [22], and more so than health-conditions-based strategies [18]. In our study, influenza vaccination status was associated with a GP recommending immunisation. Respondents reporting a physician recommendation were significantly more likely to be vaccinated for influenza. GPs, or GP practice staff, play a key role in raising awareness for influenza vaccination and increasing vaccination uptake. Such findings are consistent with other international studies; a positive attitude towards influenza vaccination following a physician’s advice was identified in France, Germany and Mexico [23]. In the US, media advertising, followed by physicians’ advice was identified as being the most important determinants of influenza vaccination [23]. These findings suggest that GP involvement in vaccination against influenza is of key importance.
4.3.1. Limitations This study is subject to several limitations. Some groups were under-represented in the sample, including those aged 25–34 years and those living in the greater metropolitan region. Recall errors may have occurred, because the reported vaccination status was based on participants’ recall. This may be an issue particularly for pneumococcal vaccination, which is not recommended annually but usually just once or sometimes twice, for those with particular risk conditions. Other studies suggested that participants’ recall is a less reliable source of information on vaccination status than records, particularly for pneumococcal vaccination [24]. This may have contributed to the low reported coverage found in this and previous studies. Selection bias may have also occurred, as a large proportion of at-risk population was not included in the study, including persons living in institutional settings such as nursing homes and hospitals, many of whom were likely to have been vaccinated [9]. Individuals in the 25–34 age group were under-represented in the study but as they were less likely to have underlying medical conditions atrisk than the older population this is unlikely to have had major effect on inclusion of individuals in at risk groups. In this study a minority of valid contacts resulted in completed surveys. This may have resulted in a greater proportion of individuals with previous experience of the disease under study (either they or a close family member or friend) more likely to participate than the general population [25]. Over estimation of the proportion of individuals at risk may have occurred due to self-reporting of chronic illness requiring medical follow up. However, as examples of possible conditions were given with this question, we believe that the information accurately reflects most conditions for which influenza vaccine is recommended.
Please cite this article in press as: Giese C, et al. Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination. Vaccine (2016), http://dx.doi.org/10.1016/j.vaccine.2016.05.028
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4.3.2. Strengths of the study The study allowed us to estimate the size of influenza and pneumococcal at-risk populations in Ireland among noninstitutionalised adults and to estimate vaccination uptake among this population. This study is the only source of data with which to estimate both the size and vaccine uptake of the 18–64 years old population at-risk for influenza and pneumococcal disease. It is also the only vaccine coverage study among all the elderly (≥65 years) regardless of GMS or GP visit card eligibility. 5. Conclusions Influenza vaccination was low in all at-risk groups (age, medical conditions and HCWs) and below the EU target. Despite improvements in HCW influenza vaccine uptake, awareness of the importance of vaccination among this group remained poor. Pneumococcal vaccination in at-risk individuals has increased over the years but remains low. The most commonly reported reason for not getting influenza vaccination was the perception of low risk. Doctors’ recommendations and access to free vaccine administration were the most important determinants of influenza vaccination. 6. Recommendations More effort is needed to increase seasonal influenza vaccination coverage in at-risk populations, especially in those <65 years of age with underlying medical conditions and HCWs. Pneumococcal vaccine uptake needs to be increased in all at-risk age groups. At GP level, local audits could be considered to monitor uptake. Specific condition-specific and age-based strategies should be adopted in order to increase vaccine uptake [18,22]. Implementing evidencebased programmes are needed to improve vaccination coverage among those with high risk conditions and health care workers [26]. GP practices should intensify communications with patients each influenza season and recommend influenza vaccination for their at risk patients with personal invitations and reminders as this was clearly identified by participants in our study has being a strong influencing factor. Intensive public information campaigns are recommended to tackle preconceived ideas on seasonal influenza vaccination, address absent or mis-information regarding risk factors for influenza and pneumococcal diseases, and remind those at-risk to get vaccinated for influenza annually. Acknowledgements The authors wish to thank all those who participated to the study and the company Milward Brown who conducted the interviews on behalf of HPSC. The study was funded by the Health Services Executive – Health Protection Surveillance Centre. Author’s contribution: Study protocol and questionnaire: JM, SC, JOD, DOF; Data analysis: CG, JM, KD, SC; Writing of article: CG, SC, JM, JOD, DOF; Reviewing of article: SC, JM, KD, JO’D, DOF. Conflict of interest statement: None of the authors have any conflict of interest to declare.
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Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Prev Med 1999;16(3):173–7. [25] Glass DC, Kelsall HL, Slegers C, Forbes AB, Loff B, Zion D, et al. A telephone survey of factors affecting willingness to participate in health research surveys. BMC Public Health 2015;October (15):1017. [26] Dexter LJ, Teare MD, Dexter M, Siriwardena AN, Read RC. Strategies to increase influenza vaccination rates: outcomes of a nationwide cross-sectional survey of UK general practice. BMJ Open 2012;2(January (3)).
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Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination Coralie Giese a,b , Jolita Mereckiene b , Kostas Danis a , Joan O’Donnell b , Darina O’Flanagan b , Suzanne Cotter b,∗ a b
European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden HSE Health Protection Surveillance Centre, Dublin, Ireland
a r t i c l e
i n f o
Article history: Received 31 December 2015 Received in revised form 10 May 2016 Accepted 11 May 2016 Available online xxx Keywords: Immunisation Influenza Pneumococcal Vaccination At-risk Elderly
a b s t r a c t The World Health Organization (WHO), and European Agencies recommend influenza vaccination for individuals at-risk due to age (≥65 years), underlying diseases, pregnancy and for health care workers (HCWs) in Europe. Pneumococcal vaccine is recommended for those at-risk of pneumococcal disease. In Ireland, vaccination uptake among at-risk adults is not routinely available. In 2013, we conducted a national survey among Irish residents ≥18 years of age, to estimate size and vaccination coverage of at-risk groups, and identify predictive factors for influenza vaccination. We used computer assisted telephone interviews to collect self-reported information on health, vaccination status, attitudes towards vaccination. We calculated prevalence and prevalence ratios (PR) using binomial regression. Overall, 1770 individuals participated. For influenza, among those aged 18–64 years, 22% (325/1485) [95%CI: 17%–20%] were at-risk; 28% [95%CI: 23%–33%] were vaccinated. Among those aged ≥65 years, 60% [95%CI: 54%–66%] were vaccinated. Influenza vaccine uptake among HCWs was 28% [95%CI: 21%–35%]. For pneumococcal disease, among those aged 18–64 years, 18% [95%CI: 16%–20%] were at-risk; 16% [95%CI: 12%–21%] reported ever-vaccination; among those aged ≥65 years, 36% [95%CI: 30%–42%] reported evervaccination. Main reasons for not receiving influenza vaccine were perceptions of not being at-risk, or not thinking of it; and among HCWs thinking that vaccination was not necessary or they were not atrisk. At-risk individuals were more likely to be vaccinated if their doctor had recommended it (PR 3.2; [95%CI: 2.4%-4.4%]) or they had access to free medical care or free vaccination services (PR 2.0; [95%CI: 1.5%-2.8%]). Vaccination coverage for both influenza and pneumococcal vaccines in at-risk individuals aged 18–64 years was very low. Influenza vaccination coverage among individuals ≥65 years was moderate. Influenza vaccination status was associated with GP vaccination recommendation and free access to vaccination services. Doctors should identify and recommend vaccination to at-risk patients to improve uptake. © 2016 Published by Elsevier Ltd.
1. Introduction Influenza is a highly infectious disease which has significant morbidity and mortality. Invasive streptococcus pneumoniae can cause serious disease or death, particularly for at-risk groups [1,2]. Both diseases are potentially vaccine preventable and there is good
∗ Corresponding author at: Health Services Executive Health Protection Surveillance Centre (HSE-HPSC), 25–27 Middle Gardiner St., Dublin 1, Ireland. Tel.: +353 1 876 5300; fax: +353 1 8561299. E-mail address: [email protected] (S. Cotter).
international evidence of which groups benefit from vaccination with either vaccine [1,2]. Most high and middle-income countries have vaccination recommendations together with funding mechanisms to encourage vaccination, particularly for influenza [3]. International studies have identified a wide range of factors associated with vaccine acceptance, including social and cultural beliefs, access to services, and public policies. Despite strong international and national vaccination recommendations uptake among risk groups there has been little progress made in Ireland in recent years [3]. The European Commission (EC) recommends that all EU countries monitor seasonal influenza vaccination coverage in high risk groups. The World
http://dx.doi.org/10.1016/j.vaccine.2016.05.028 0264-410X/© 2016 Published by Elsevier Ltd.
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Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) have defined risk groups for influenza as persons at higher risk of having an adverse outcome (e.g. severe disease or death) from infection, including individuals aged ≥65 years, those with specified medical conditions (including pregnancy), and health care workers (HCWs) [4,5]. Invasive pneumococcal disease is a particular risk for the very young, the elderly and those with chronic medical conditions [6]. 1.1. At-risk populations and vaccination programme in Ireland In Ireland, the National Immunisation Advisory Committee (NIAC) makes vaccine recommendations for the population. Risk groups identified are similar to those identified internationally [2,6,7]. The Health Services Executive of Ireland (HSE) supports the influenza and pneumococcal vaccination programme for those in at-risk groups by providing free vaccines. Vaccine administration fees may apply for individuals ineligible for free access to primary care services (General Medical Service [GMS] medical card or GP visit [GPV] card) [8]. Eligibility for free primary care services is usually income dependent. HCWs are entitled to free vaccine administration (occupational health services). The HSE-National Immunization Office (HSE-NIO) procures and distributes influenza vaccine to health care facilities (hospitals, long-term care facilities, GP practices and community pharmacies). Pneumococcal vaccines are provided to GP sites. HSE-NIO promotes these vaccines using a variety of media (radio or television, leaflets, posters). 1.2. Influenza and pneumococcal vaccine uptake in at-risk populations In Ireland, there is no comprehensive information system with which to estimate uptake of influenza or pneumococcal vaccines among at-risk adults. In an effort to fill this gap the Health Protection Surveillance Centre (HPSC) uses administrative data (payment claims from GP or pharmacies) to estimate uptake among elderly entitled to free vaccination. For HCWs, surveys of health care facilities have been done since 2011 [9]. Previous work done by HSE-NIO in 2011 identified potential barriers to influenza vaccination (including low risk perception, concerns about vaccine side effects and costs of vaccine administration) [10]. Between August and October 2013, we undertook a survey from a sample of the Irish adult population to: estimate the proportion of community-based adults who had risk conditions, or were HCWs, for whom influenza or pneumococcal vaccination was recommended; estimate vaccination coverage among those groups; and identify factors associated with seasonal influenza vaccination status during the influenza season 2012–2013.
We estimated the sample size Open Epi, version 3 (http://www. openepi.com/v37/SampleSize/SSPropor.htm). Assuming that 11% of those with underlying conditions belong to the risk groups for influenza, [11] a sample size of 1700 persons was required for a desired precision ±1.5%. Random digital dialling was applied for generating telephone numbers for landline and mobile phones. We excluded persons living in institutional settings and those unable to complete the telephone interview due to language or speech difficulties. A market research company specialising in CATI carried out the survey and recruited participants.
2.3. Data collection We developed a standardised questionnaire similar to those previously used (2006, 2010). We sought information on respondent’s age, gender, residential area according to HSE administrative region; vaccination status (seasonal influenza, pneumococcal vaccines), reasons for getting/not getting influenza vaccines, medical risk conditions (diagnosed by doctor), or occupational risk. Trained interviewers administered questionnaires and entered data onto the database at time of interview. The interviews were done between August 28th and October 14th, 2013 during days and evenings. One adult person per household was interviewed. If there were two eligible adult persons who consented to being interviewed, the person who fulfilled the age group and gender quota or with the next birthday was interviewed.
2.4. Operational definitions For the purpose of this study we defined risk groups for whom influenza vaccine was recommended as those who were aged 65 years or more; participants who reported having any underlying medical conditions which were identified by using simple questions asked to each participant if they had any of the following conditions for which influenza vaccine is indicated; asthma, any chronic lung disease, any condition of nervous system that may affect respiratory function; any chronic illness requiring medical follow up or hospitalisation (e.g. diabetes, kidney disease, inherited blood disorder, metabolic diseases or cancer); on any medication that may affect immune system; having had a heart attack or stroke; chronic heart disease; morbid obesity or being pregnant during the previous influenza season [7]. We defined individuals as being atrisk for pneumococcal disease if they were aged 65 years and over or reported a medical condition for which pneumococcal vaccination was indicated (asthma, condition of nervous system that may affect respiratory function, chronic illness requiring medical follow up or hospitalisation, chronic lung disease, being on medication that may affect immune system, or reported previous heart attack or stroke).
2. Method 2.1. Study design and population We conducted a national telephone survey among adults aged 18 years and over, residing in Ireland (non-institutionalised), using computer assisted telephone interviews (CATI). This survey followed similar methodology to previous national telephone surveys in 2006 [11] and in 2010 [12]. 2.2. Sampling methods We used quota sampling methods. Quota sampling reflected the demographics based on age, sex and region of residence of the Irish population.
2.5. Data analysis We calculated frequencies and proportions of all categorical variables. We calculated prevalence ratios (PR) and 95% confidence intervals (95%CI) using binomial regression.
2.6. Ethical issues Oral informed consent was obtained from all respondents. Questionnaires did not have personal identification details. All information was confidential and protected by the Irish Data Protection Act 2003. Ethics approval was granted from the Royal College of Physicians of Ireland for this study.
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Table 1 Comparison of respondents with 2011 census adult population in terms of age group, gender, and region. Adult vaccine uptake survey, Ireland, August 2013. CSOa data (2011 census)
Survey
p value
n
(%)
95%CI
Population
(%)
Age group 18–24 25–34 35–49 50–64 65+ Total
214 340 516 415 285 1770
12 19 29 23 16 100
11–14 17–21 27–31 22–26 14–18 –
411,153 755,067 1,000,258 737,694 535,393 3,439,565
12 22 29 21 16 100
0.045
Gender Male Female Total
863 907 1770
49 51 100
46–51 49–54 –
1,684,917 1,754,648 3,439,565
49 51 100
0.847
HSE region HSE-E HSE-M HSE-MW HSE-NE HSE-NW HSE-S HSE-SE HSE-W Total
768 67 191 243 76 158 137 130 1770
43 3.8 11 14 4.3 8.9 7.7 7.3 100
41–46 2.9–4.8 9.4–12 12–15 3.4–5.3 7.6–10 6.5–9.1 6.2–8.7 –
1,236,870 204,684 284,338 317,781 191,004 501,146 368,170 335,572 3,439,565
36 6 8.3 9.2 5.6 15 11 9.8 100
<0.001
a
Central Statistics Office.
3. Results 3.1. At-risk population in Ireland Of 18,238 valid telephone contacts made, we interviewed 1770 (10%) persons. Compared with 2011 census data, those in the 25–34 years age group were under-represented, while those in 50–64 year age group were over-represented; those in the HSE Eastern region
(HSE-E), which includes the greater Dublin metropolitan area were over-represented (Table 1). Among all respondents, 35% (610/1770) [95%CI: 32%–37%] were at-risk for influenza due to age or medical conditions; 16% (285/1770) [95%CI: 14%–18%] were aged ≥65 years and were therefore at-risk for both influenza and pneumococcal diseases (Table 2). Among those aged 18–64 years, 22% (325/1485) [95%CI: 17%–20%] were at-risk for influenza due to underlying medical
Table 2 Seasonal influenza vaccine uptake since September 1st 2012 (season 2012–13) and pneumococcal vaccine (ever) uptake, adult vaccine uptake survey, Ireland, August 2013.
Overalla Sex Female Male Age group 18–24 25–34 35–49 50–64 65+ Health care worker (HCW) Persons over 65 yearsb Persons aged 18–64 with medical conditionsc (average for at least one medical condition) Asthma Chronic heart disease Heart attack or stroke Under medication that may affect immune system Lung disease Chronic illness requiring medical follow up or hospitalisation Condition of nervous system affecting respiratory function Pregnantd Obesity a b c d
Vaccine uptake for seasonal influenza
Vaccine uptake for pneumococcal disease
Proportion population %
Vaccinated
Total
%
95%CI (%)
Vaccinated
Total
%
95%CI (%)
100
370
1770
21
19 to 23
185
1695
11
9.4 to 12
51 49
178 192
904 858
20 22
17 to 22 20 to 25
94 91
878 817
11 11
8.7 to 12 9.0 to 13
12 19 29 23 16 9.3 16 22
18 29 61 93 169 46 169 90
214 340 516 415 285 164 282 324
8 9 12 22 59 28 60 28
5.1 to 13 5.8 to 12 9.1 to 15 18 to 27 53 to 65 21 to 35 54 to 66 23 to 33
23 16 18 30 98 – 98 41
198 325 499 402 271 – 271 250
12 5 4 7 36 – 36 16
7.2 to 16 2.6 to 7 2.0 to 5 4.9 to 10 30.4 to 42 – 30 to 42 12 to 21
8.6 1.9 1.4 3.7
29 12 9 22
126 28 21 197
23 43 43 40
16 to 31 23 to 64 20 to 66 27 to 53
19 6 – 12
119 28 – 52
16 21 – 23
9.3 to 23 5.2 to 38 – 11 to 35
0.9 7.7
5 45
14 114
36 40
7.0 to 64 30 to 49
4 23
14 106
29 22
1.5 to 56 14 to 30
1.1
3
16
19
−2.7 to 40
2
15
13
−6.2 to 33
7.4 1.8
10 8
45 26
22 31
9.6 to 35 12 to 50
– –
– –
– –
– –
75 missing values on pneumococcal vaccination status. 3 missing values on influenza vaccination status and 14 missing values on pneumococcal vaccination status. 1 missing value on influenza vaccination status and 14 missing values on pneumococcal vaccination status. restricted to women 18–54 pregnant between September 2012–October 2013.
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Table 3 Reported reasonsa for not getting seasonal influenza vaccines among adults by at-risk groups for influenza season 2012–13, Ireland, August 2012 (n = 1392). All respondents
Perceptions of low risk Not needing influenza vaccination I Don’t get the flu I am not at riskc I don”t like injections/going to the doctor It doesn”t work/is ineffective I may get the flu from it, I fear the side effects I got the flu from it last time, it has side effects on me Problems with awareness/access/affordability Did not think about it, forgot to ask about it this year No time, I didn’t get around to it Didn’t know the flu injection was available to me Wasn’t offered the flu injection by my family doctor/GP Other reason No reason a b c
18–64 with underlying medical conditions
Over 65
HCWsb
n
%
95%CI (%)
n
%
95%CI (%)
n
%
95%CI (%)
n
%
95%CI (%)
397 277 162 42 34 31 28
29 20 12 3.0 2.4 2.2 2.0
26–31 18–22 10–13 2.2–4.1 1.7–3.4 1.5–3.2 1.3–2.9
58 32 27 5 13 9 5
25 14 12 2.1 5.6 3.9 2.1
19–31 9.5–19 7.7–16 0.7–4.9 3.0–9.3 1.8–7.2 0.7–4.9
26 17 3 8 3 3 4
23 15 2.7 7.1 2.7 2.7 3.5
16–32 9.0–23 0.6–7.6 3.1–14 0.6–7.6 0.6–7.6 1.0–8.8
39 17 14 2 3 3 5
33 14 12 1.7 2.5 2.5 4.2
25–42 8.6–22 6.6–19 0.2–6.0 0.5–7.2 0.5–7.2 1.4–9.6
150
11
9.2–13
29
12
8.5–17
22
20
13–28
5
4.2
1.4–9.6
62 30
4.5 2.2
3.4–5.7 1.5–3.1
16 4
6.8 1.7
4.0–11 0.5–4.3
4 –
3.5 –
1.0–8.8 –
7 1
5.9 0.9
2.4–12 0.02–4.6
25
1.8
1.2–2.6
4
1.7
0.5–4.3
6
5.3
2.0–11
4
3.4
0.9–8.5
55
4.0
3.0–5.1
7
3.0
1.2–6.1
5
4.4
1.5–10
5
4.2
1.4–9.6
One (first) reason given per participant when asked for reason for non-vaccination. Health care worker. Only for people with pre-existing health conditions, elderly or pregnant.
conditions. Of all participants, 164 (9.3%) [95%CI: 0.8%–11%] were HCWs; of whom 36 (22%) also had a medical or age related risk for influenza (Table 2). Regarding pneumococcal disease, 31% (549/1770) [95%CI: 29%–33%] of all respondents reported being at-risk, including 18% (264/1485) [95%CI: 13%–17%] of those aged 18–64 years.
3.2. Influenza and pneumococcal vaccine uptake in at-risk populations Among those in the 18–64 year age group for whom seasonal influenza vaccine was recommended, 28%(90/324) [95%CI: 23%–33%] were vaccinated; in those aged ≥65 years, 60%(169/282) [95%CI: 54%–66%] were vaccinated (Table 2). Overall vaccine uptake in HCWs was 28% (46/164) [95%CI: 19%–23%] (Table 2); but varied by risk group and age. Vaccine uptake for HCWs with no medical or age related risk was 24% (31/129) [95%CI: 17%–32%]; 75% [95%CI: 19%–99%] among HCWs aged ≥65 years; and 39% (12/31) [95%CI: 22%–58%] among those with medical conditions. Among those for whom pneumococcal vaccine was recommended; 16% (41/250) [95%CI: 12%–21%] of those aged 18–64 years reported ever being vaccinated; and 36% (98/271) [95%CI: 30%–42%] of those aged ≥65 years (Table 2). 3.3. Barriers and predictors for vaccination 3.3.1. Reported reasons for not being vaccinated Amongst those aged 18–64 years for whom seasonal influenza vaccination was indicated, reasons for non-vaccination included: vaccination was not necessary for them (25% [95%CI: 19%–31%]); rarely getting influenza (14% [95%CI: 9.5%–19%]); not thinking about it (12% [95%CI: 8.5%–17%]); or not considering themselves at-risk (12%[95%CI: 7.7%–16%]) (Table 3). Similar reasons were reported amongst those aged 65 years and over who were not vaccinated. The main reasons for non-vaccination reported by HCWs were that vaccination was not necessary for them (33% [95%CI: 25%–42%]), they rarely get influenza (14% [95%CI: 8.6%–22%]) or they considered themselves not at- risk (12% [95%CI: 6.6%–19%]).
3.3.2. Factors associated with vaccination Overall, individuals belonging to at-risk groups for influenza were more likely to be vaccinated if their doctor had recommended it even when they did not have a medical card/GP visit card (PR 3.2; [95%CI: 2.4–4.4]; p < 0.001). If they had a medical card/GP visit card but vaccination hadn’t been recommended by their doctor (PR 2.0; [95%CI; 1.5–2.8]; p < 0.001) (data not shown in table), they were still likely to be vaccinated. Additionally, 36% of all those in at risk groups reported that they got the vaccine because their doctor recommended it.
4. Discussion The survey provided information on vaccination uptake for those at-risk population groups for whom there is little available data. For influenza, overall vaccine uptake among at-risk populations was below the EU/WHO recommended target of 75%. For pneumococcal vaccination, vaccination uptake, as found in this study, was poor despite long standing recommendations in Ireland.
4.1. At-risk population in Ireland In this study, the estimated proportion of individuals aged 18–64 with underlying medical conditions for influenza (22%) was higher than previously reported prevalence estimates from the UK and ECDC but higher than that reported in the 2006 national telephone survey (11%) [11]. However, the criteria for medical or underlying conditions in the UK study excluded a number of risk factors that were included in our survey, such as obesity and other nonspecified chronic medical conditions that may require medical follow up [5]. Pregnancy was also included in our study as a risk condition. Our findings are compatible with date obtained in the 2011 national census when between 23% and 42% of individuals aged 18–64 years reported having a doctor diagnosed medical condition, most of which necessitated long term follow-up [13]. These differences would we believe account for the differences found.
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4.2. Influenza and pneumococcal vaccine uptake in those populations 4.2.1. Influenza vaccination Influenza vaccine uptake among individuals aged 18–64 with underlying medical conditions, in those aged ≥65 years and in HCWs remained far below the EU target of 75% by 2014–15 for all at-risk populations [6]. Among persons aged 18–64 years with underlying medical conditions, estimated vaccine uptake for seasonal influenza vaccine in this study, was similar to the 2006 (27%) and 2010 (29%) national telephone surveys [11,12]. For individuals aged 65 years and over, our estimated influenza vaccine uptake was similar to what was reported by the General Medical Card (GMS) for the same season [14]. This is less than that reported in the 2006 and 2010 surveys (69% and 64% respectively) but the difference is not statistically significant. It is not clear whether this slight decrease in uptake is due to concerns related to the vaccine safety, highlighted after the pandemic influenza vaccine, or other unidentified factors. Several studies in France, Germany and Spain have indicated that influenza vaccination coverage in targeted populations decreased in post-pandemic seasons [15–17]. In Spain, vaccine coverage decreased to 58% in 2011–12, compared with 64% and 67% in 2003 and 2006, respectively [18]. Our estimated vaccine uptake among HCWs for seasonal influenza vaccine in 2013 was similar to that estimated in a similar survey in 2010 (27%) and although greater than that reported in 2006 (20%) survey was not statistically significant [11]. Uptake reported in this survey was higher than that reported from the National Survey of hospitals and long-term care facilities for the 2012–13 season where average uptake among HCWs working in hospitals and long term care facilities was estimated at 24% and 23% respectively [9]. The higher self-reported uptake from this telephone survey may reflect that more HCWs are vaccinated outside the hospital and long term care facility occupational health settings and their vaccination records are not reflected in management figures. As HCWs are strongly recommended vaccination in Ireland the reported uptake rates are particularly concerning and highlights the need for implementation of specific strategies and programmes for this priority group if targets are to be achieved [4,6]. 4.2.2. Pneumococcal vaccination Since the initial national telephone survey in 2006 and in the 2010 and 2013 survey (as reported in this paper) reported uptake of pneumococcal vaccine has increased among those with underlying medical conditions in the 18–64 years age group (11%, 12% and 14%, respectively). Pneumococcal vaccine uptake in the older population was more than double that reported in the younger at risk groups, with reported uptake in the 65 years and older age groups increasing with each subsequent survey (27%, 33% and 36% in 2005, 2010 and 2013, respectively). Despite this improvement, the overall low uptake still highlights that at-risk populations are not getting the vaccine. Other developed countries such as the USA have achieved higher coverage for at-risk groups, with researchers from the US reporting in 2013 uptakes of (21%) in the 19–64 years at-risk and (60%) among adults aged 65 years or older [19]. We did not investigate the reasons for not being vaccinated with pneumococcal vaccine in this study. A Canadian study among adults 65 years of age or older identified a positive correlation between vaccination recommendations from a HCW with vaccination status [20]. 4.3. Attitudes towards and predictors of influenza vaccination The most common reason reported by at-risk participants who were unvaccinated for influenza was a perception of being at low
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risk. Similar findings were reported in the 2010 telephone survey [12] and HSE-NIO study in2011 [10]. This indicates limited awareness of the benefits of vaccination and of the seriousness of the infection among the at-risk population, and especially among HCWs. Access to free vaccine administration was associated with influenza vaccination status. Even for HCWs, free access to vaccines has been found to be associated with improving vaccination uptake. One Australian study found that vaccine uptake was higher in GPs working at practices that provided free vaccine for influenza (85% versus 58%) and that paying for vaccine was identified as a barrier by 25% of respondents [21]. We found in this study that some individuals from the targeted population, and especially those aged 65 years and over, may forget and not think about getting vaccinated, highlighting the importance of health care provider reminder/recommendation. Other studies have suggested that age-based strategies to increase vaccine uptake were efficient [22], and more so than health-conditions-based strategies [18]. In our study, influenza vaccination status was associated with a GP recommending immunisation. Respondents reporting a physician recommendation were significantly more likely to be vaccinated for influenza. GPs, or GP practice staff, play a key role in raising awareness for influenza vaccination and increasing vaccination uptake. Such findings are consistent with other international studies; a positive attitude towards influenza vaccination following a physician’s advice was identified in France, Germany and Mexico [23]. In the US, media advertising, followed by physicians’ advice was identified as being the most important determinants of influenza vaccination [23]. These findings suggest that GP involvement in vaccination against influenza is of key importance.
4.3.1. Limitations This study is subject to several limitations. Some groups were under-represented in the sample, including those aged 25–34 years and those living in the greater metropolitan region. Recall errors may have occurred, because the reported vaccination status was based on participants’ recall. This may be an issue particularly for pneumococcal vaccination, which is not recommended annually but usually just once or sometimes twice, for those with particular risk conditions. Other studies suggested that participants’ recall is a less reliable source of information on vaccination status than records, particularly for pneumococcal vaccination [24]. This may have contributed to the low reported coverage found in this and previous studies. Selection bias may have also occurred, as a large proportion of at-risk population was not included in the study, including persons living in institutional settings such as nursing homes and hospitals, many of whom were likely to have been vaccinated [9]. Individuals in the 25–34 age group were under-represented in the study but as they were less likely to have underlying medical conditions atrisk than the older population this is unlikely to have had major effect on inclusion of individuals in at risk groups. In this study a minority of valid contacts resulted in completed surveys. This may have resulted in a greater proportion of individuals with previous experience of the disease under study (either they or a close family member or friend) more likely to participate than the general population [25]. Over estimation of the proportion of individuals at risk may have occurred due to self-reporting of chronic illness requiring medical follow up. However, as examples of possible conditions were given with this question, we believe that the information accurately reflects most conditions for which influenza vaccine is recommended.
Please cite this article in press as: Giese C, et al. Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination. Vaccine (2016), http://dx.doi.org/10.1016/j.vaccine.2016.05.028
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4.3.2. Strengths of the study The study allowed us to estimate the size of influenza and pneumococcal at-risk populations in Ireland among noninstitutionalised adults and to estimate vaccination uptake among this population. This study is the only source of data with which to estimate both the size and vaccine uptake of the 18–64 years old population at-risk for influenza and pneumococcal disease. It is also the only vaccine coverage study among all the elderly (≥65 years) regardless of GMS or GP visit card eligibility. 5. Conclusions Influenza vaccination was low in all at-risk groups (age, medical conditions and HCWs) and below the EU target. Despite improvements in HCW influenza vaccine uptake, awareness of the importance of vaccination among this group remained poor. Pneumococcal vaccination in at-risk individuals has increased over the years but remains low. The most commonly reported reason for not getting influenza vaccination was the perception of low risk. Doctors’ recommendations and access to free vaccine administration were the most important determinants of influenza vaccination. 6. Recommendations More effort is needed to increase seasonal influenza vaccination coverage in at-risk populations, especially in those <65 years of age with underlying medical conditions and HCWs. Pneumococcal vaccine uptake needs to be increased in all at-risk age groups. At GP level, local audits could be considered to monitor uptake. Specific condition-specific and age-based strategies should be adopted in order to increase vaccine uptake [18,22]. Implementing evidencebased programmes are needed to improve vaccination coverage among those with high risk conditions and health care workers [26]. GP practices should intensify communications with patients each influenza season and recommend influenza vaccination for their at risk patients with personal invitations and reminders as this was clearly identified by participants in our study has being a strong influencing factor. Intensive public information campaigns are recommended to tackle preconceived ideas on seasonal influenza vaccination, address absent or mis-information regarding risk factors for influenza and pneumococcal diseases, and remind those at-risk to get vaccinated for influenza annually. Acknowledgements The authors wish to thank all those who participated to the study and the company Milward Brown who conducted the interviews on behalf of HPSC. The study was funded by the Health Services Executive – Health Protection Surveillance Centre. Author’s contribution: Study protocol and questionnaire: JM, SC, JOD, DOF; Data analysis: CG, JM, KD, SC; Writing of article: CG, SC, JM, JOD, DOF; Reviewing of article: SC, JM, KD, JO’D, DOF. Conflict of interest statement: None of the authors have any conflict of interest to declare.
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Please cite this article in press as: Giese C, et al. Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination. Vaccine (2016), http://dx.doi.org/10.1016/j.vaccine.2016.05.028