Mener une campagne de vaccination contre la grippe saisonnière reste un point essentiel et incontournable pour tout établissement hospitalier travaillant dans l’intérêt des patients, des visiteurs et de son personnel. La vaccination permet de limiter la contamination et la propagation du virus influenza, cet enjeu de santé publique demeure l’une des priorités de la promotion pour la santé. De plus, la démarche d’amélioration continue ainsi que la culture actuelle de sécurité et de qualité doivent motiver chacun à persévérer et à trouver de nouvelles stratégies, convaincu de la plus-value indéniable en santé.  

Dans le cadre d’études en master en sciences de la santé publique à l’Université Catholique de Louvain, j’ai rédigé en 2018 un mémoire, encadré par Mme Anne Simon et Mr William D’Hoore, ayant pour titre « Connaissances, perceptions et attitudes du personnel de santé du Centre Hospitalier de Mouscron vis-à-vis de la vaccination contre la grippe saisonnière » ⁽²⁾. Mon intérêt s’est porté sur cette thématique par un constat simple : le taux de vaccination au sein de mon institution historiquement bas et une remarque d’amélioration demandée par l’organisme d’accréditation internationale venu au sein de l’établissement en 2016. Coïncidence de calendrier, si 2018 ne révélait aucune particularité à propos de la grippe, un bien triste anniversaire resurgissait brutalement : 1918, sa pandémie de grippe espagnole et ses 20 millions de décès (ou plus). Et nous voici donc, un siècle plus tard, à devoir réfléchir encore et toujours à fédérer les énergies pour la lutte contre ce virus… 

Pourtant, l’Organisation Mondiale de la Santé (2010) ^(8,9) nous confirmait à propos de la vaccination qu’« à l’exception de l’eau potable, il n’y a rien d’autre, même pas les antibiotiques, qui ait eu un effet si important sur la réduction de la mortalité…». Que faut-il de plus pour convaincre les professionnels de la santé, ou chacun d’entre nous, du bénéfice réel de la vaccination contre la grippe saisonnière ?

Pour tenter d’expliquer cela, mon mémoire s’est composé d’un cadre théorique et d’une revue de littérature, dont les points essentiels vous seront exposés un peu après. Ensuite, les parties « méthode » et « résultats » abordaient la composition ainsi que l’analyse du questionnaire que j’ai élaboré, testé et validé. Chaque thématique fut investiguée par différentes propositions (échelle de likert) offrant la possibilité au répondant de dire s’il pensait que la phrase était ‘très favorable’, ‘favorable’, ‘ni favorable, ni défavorable’, ‘défavorable’ ou ‘très défavorable’ à la vaccination. Le questionnaire se développait avec les premières caractéristiques suivantes : le sexe, la tranche d’âge, le service, la fonction. Ensuite le personnel était invité à donner son avis à propos de 48 facteurs, répartis dans 6 catégories à savoir : la grippe, le vaccin, l’organisation, la communication, les agissements et les facteurs influençant le personnel de santé. Une grande majorité de ces critères provenaient du modèle PRECEDE de Green L.W. et Kreuter M.W. (1991) ⁽³⁾. En effet, ce modèle permet, entre autres, de déterminer des facteurs prédisposants, facilitants et de renforcement d’un comportement spécifique. Ces différents facteurs tels que les connaissances, les attitudes, les croyances, les capacités, les ressources, le rôle des pairs etc. influencent le comportement adopté. Il paraissait donc tout à fait adapté pour mon analyse. Enfin, une ultime question permettait d’identifier dans quel groupe le répondant se trouvait : vacciné ou non vacciné.

Le public cible choisi était le personnel hospitalier. J’ai décidé de me focaliser sur celui-ci car d’une part il représentait les individus en contact direct et prolongé avec le patient, d’autre part par la faisabilité de l’enquête pour moi, étudiant de master. Mon questionnaire fut donc remis à 522 membres du personnel paramédical (infirmier(e)s, accoucheuses, aide-soignant(e)s) et à 100 membres du corps médical, avec un taux de répondants global (validés et exploités) de 52,57%. Malgré tout, parmi tous ces questionnaires et dans ce chiffre annoncé, il y eut des observations manquantes. Même si celles-ci l’ont été de façon aléatoire, il n’en restait pas moins que tous les questionnaires n’étaient pas complets à 100%. L’échantillon considéré pour certaines analyses n’était donc pas tout à fait le même que l’échantillon de départ. 

Les questionnaires sélectionnés furent encodés dans le logiciel d’analyse statistique et prédictive IBM SPSS® Dans un premier temps et afin d’y voir plus clair, le choix de la première analyse, faite à partir de notre logiciel, fut d’utiliser la comparaison par la moyenne et l’écart-type pour chaque énoncé. Cela a permis de résumer en une vue les différentes questions d’une même thématique, ce qui se révéla être un net avantage à la compréhension. Les constations principales furent que les individus les plus âgés étaient significativement plus vaccinés que les plus jeunes, que certains services tels que le pôle médicotechnique, la maternité, la pédiatrie représentaient des services moins vaccinés, que le personnel ayant une fonction hiérarchique était mieux vacciné que leurs subordonnés et enfin que la fonction médicale obtenait le meilleur taux de vaccination, opposé à la fonction accoucheuse. Enfin, un constat global concerne le groupe de personnel non vacciné qui avait répondu de manière assez peu investie, dans le sens où ils n’avaient pas donné un avis catégorique et assuré vis-à-vis du choix de ne pas se faire vacciner. Cette constatation a priori négative pouvait en fait être un atout… Ensuite, le test T de Student nous a permis d’identifier les différences statistiques significatives de chaque question en comparaison des deux groupes. Cette étape autorisait la mise en évidence de variables utiles à analyser dans une troisième étape, par la régression pas à pas ascendante. Lors de ce dernier test statistique, la variable la plus fortement associée à la vaccination était les recommandations du supérieur hiérarchique. Par ailleurs, le rôle protecteur individuel et collectif, le rapport risques-bénéfices et l’image positive de soi étaient des facteurs favorisant la vaccination. Par contre, l’ignorance s’était révélée être un facteur défavorable. 

Certaines limites avaient pu être mises en évidence après l’analyse, de même certaines formes de biais avaient également pu être constatées. C’est en tenant compte de cela et du contexte, de l’objectif recherché, de l’humilité accordée à mon travail de recherche dans le cadre d’un master de santé publique que des propositions avaient pu être énoncées.

Mais revenons sur l’objectif de ce mémoire qui était de déterminer les facteurs influençant l’adhésion à la vaccination antigrippale. Et, force est de constater que je ne suis pas seul à vouloir tenter de les identifier. C’est ce qui m’a poussé à partager les résultats de ma recherche et mon expérience professionnelle vivant probablement de mon côté une réalité semblable à celle vécue au sein des autres hôpitaux Wallons ou Bruxellois… 

Cet article a pour intérêt de vous partager les points qui, selon moi, apportent un intérêt et une valeur pertinents à considérer pour vos prochaines campagnes. Ces différents points proviennent de la rédaction de mon mémoire, de la littérature scientifique parcourue, des résultats de mon enquête par questionnaire au sein du Centre Hospitalier de Mouscron (C.H.M.) mais également par ma propre expérience issue de la campagne précédente. Ce travail de réflexion avait pu être structuré sur base du « Guide de mise en œuvre de la stratégie multimodale de l’OMS pour la Promotion de l’hygiène des mains » (OMS, 2010). J’avais alors adapté les principaux éléments de la stratégie multimodale à la vaccination contre la grippe saisonnière pour élaborer notre propre démarche stratégique. En effet, l’intérêt de ce mémoire ne se limitait pas à un simple exercice de rédaction. Les principaux résultats ainsi que le travail mené en amont ont convaincu la Direction du C.H.M. de mettre en application les propositions faites pour la campagne 2018-2019. Cette prise de conscience et les efforts de chacun ont permis au taux de vaccination de faire un bond en avant indéniable cette année-ci de près de 25% par rapport à l’année précédente ! 

Comme annoncé plus en amont, voici quelques éléments qui pourraient, entre autres, expliquer la situation actuelle et ce taux largement inférieur à nos attentes : 

Alors que Lehmann B.A., et al. (2016) ⁽⁴⁾ résument, dans leur article, diverses études démontrant que la prévention dans les soins de santé des infections acquises ou nosocomiales est un objectif important pour la sécurité des patients et le contrôle des infections dans tous les milieux de soins, un constat m’interpelle : On estime que 20% des travailleurs de la santé sont infectés chaque année par la grippe. Beaucoup d’entre eux continuent à travailler et favorisent ainsi la propagation de la grippe. Par ailleurs, même si le personnel bienveillant pense être à même d’identifier les symptômes grippaux dès leur apparition et déclare se rendre de suite auprès de leur médecin traitant, il ignore probablement qu’un patient ayant contracté le virus est infectieux un jour déjà avant la survenue de symptômes et le reste généralement pendant 5 à 7 jours. (Bragard C. et al., s.d.) ⁽¹⁾

Dans le même sens, Leroy R. (2008) ⁽⁵⁾ cite une étude de Elder A. et al., à propos du pourcentage d’autodiagnostic erroné important. Nous y apprenons que 30% des sujets affirment avoir eu la grippe alors qu’ils sont séronégatifs et 59% des sujets ne pensent pas avoir eu la grippe alors qu’ils sont séropositifs. Cela montre bien toute la difficulté de distinguer la grippe des autres virus circulant en hiver.  

Et si les réticences à l’égard du vaccin contre la grippe étaient liées à la crainte des effets secondaires ? Ces risques liés au vaccin dépasseraient-ils le bénéfice perçu de cette même vaccination ? C’est ce que Lévy-Bruhl D. (2016) ⁽⁶⁾ expose à travers le modèle d’évolution d’un programme de vaccination au fil du temps de Chen RT (1996) où la dynamique d’un programme de vaccination est à chaque instant la résultante de paramètres en interaction : l’incidence de la maladie, la couverture vaccinale et la fréquence des effets secondaires. En effet, au début, l’incidence de la maladie est élevée, les éventuels effets secondaires du vaccin sont acceptés au regard des complications de la maladie. Au fur et à mesure de l’élévation de la couverture, la fréquence de la maladie et de ses complications diminue alors que celle des effets secondaires augmente, en raison du nombre plus élevé de vaccinations effectuées. L’efficacité sur la maladie fait oublier cette dernière et seuls restent visibles les effets secondaires, réels ou supposés, de la vaccination. La recrudescence des cas de coqueluche reflète parfaitement cette théorie.

Un autre élément qui ne joue pas en faveur du vaccin, c’est que l’influenza A H1N1, A H3N2 et l’influenza B Victoria, B Yamagata circulant chez l’homme se modifient en permanence et entrainent l’apparition de nouvelles souches. Pour l’instant, ceci rend impossible la présence d’une immunité durable. Et il est vrai que même si la grippe est en général une maladie bénigne, il n’en est pas moins qu’elle peut devenir mortelle pour certaines personnes à risque.

Les institutions de soins se confrontent alors à un dilemme : respecter la liberté individuelle et recourir à des manœuvres d’information, d’éducation, de motivation, de valorisation, etc… ou rendre la vaccination contre influenza obligatoire légalement ou du moins éthiquement. 

C’est ce que les auteurs américains Sydnor E. et Perl T.M.
(2014) ⁽¹⁰⁾, qui ont publié sur les professionnels des soins de santé comme sources de maladies évitables par la vaccination, nous disent : en ce qui concerne la vaccination de l’influenza, plusieurs discussions juridiques et éthiques sur la question ont été publiées et ont estimé que la prise en compte des droits des patients à la sécurité l’emportait sur le droit individuel à l’autonomie. En réponse à ces taux faibles, plusieurs systèmes de santé ont fait de la vaccination antigrippale des professionnels de santé une condition d’emploi. La mise en œuvre de politiques obligatoires de vaccination antigrippale a fait passer les taux de vaccination des professionnels de santé à plus de 95% dans de nombreux systèmes. » (Traduction libre de l’anglais). De même, Locoge Th. et Van Geet Ch. (2016) ⁽⁷⁾ se sont questionnées sur « Est-il éthiquement acceptable qu’une personne refuse de se faire vacciner? » et concluent que l’un des buts de la vaccination est de protéger la personne elle-même contre une maladie donnée mais une autre finalité de la vaccination concerne la protection d’autrui, dont les concitoyens malades, les patients, l’ensemble de la collectivité. D’un point de vue éthique, il est très important de contribuer à cet objectif. Pour les membres du Comité consultatif, il est difficilement compréhensible et éthiquement interpellant que seule une fraction limitée des prestataires de soins actifs dans les hôpitaux et les établissements de soins se fasse vacciner contre la grippe tous les ans.

En ce qui concerne mon expérience de terrain lors de la campagne précédente, la direction m’avait demandé de venir présenter mes constatations ainsi que mes propositions dès septembre 2018 auprès du Comité d’Hygiène, du Comité pour la prévention et la protection au travail (CPPT) et lors de la réunion des infirmiers en chef avec la direction de nursing. La communication et la persuasion devaient passer par ces différents intervenants. Si les représentants des Directions et les preneurs de décision ne sont pas convaincus du bien-fondé de la démarche, s‘ils ne montrent pas l’exemple cela impactera négativement la vaccination. L’influence de l’autorité a d’ailleurs été démontrée comme un facteur favorable à la vaccination, selon l’analyse statistique de mon étude. Par la suite, j’ai eu l’occasion de présenter mes recommandations auprès de l’équipe des référents en hygiène puis auprès des assistants de médecine. A nouveau, il fallait trouver un public capable de transmettre au sein des différents services une attitude pro vaccinale mais également leur donner des armes pour répondre, informer et convaincre les personnes réticentes. Convaincre, ce terme revient souvent et révèle toute son importance car, à travers les résultats de mon mémoire et mes contacts lors de la campagne, j’ai pu constater que finalement celles et ceux qui ne se faisaient pas vacciner ne parvenaient pas à justifier pourquoi. En fait de nombreux non vaccinés n’étaient pas contre la vaccination. Il s’agirait davantage de négligence, désintérêt, ignorance, manque de motivation ou d’implication par exemple. 

Ces exposés à des publics divers se sont déroulés en parallèle d’une campagne de communication multi supports (emails, posters, fonds d’écran, affichage sur l’intranet, distribution de badge au vacciné, …), du libre accès au vaccin sans inscription préalable, de l’élargissement des périodes de vaccination au sein de la médecine du travail, de la mise en place d’une équipe mobile qui passait régulièrement au sein des unités et se plaçait dans des endroits stratégiques tels qu’aux sorties de réunion ou de staff, à l’entrée du restaurant du personnel ou autre. Nous avons également orienté nos actions avec une attention particulière destinée aux plus jeunes, aux services et fonctions les moins vaccinés. A propos des plus jeunes, j’en profite pour relayer la remarque perspicace de Mme Yvette Vermeersch de l’UCL Saint-Luc, membre du jury et lectrice de mon mémoire, qui insistait sur la formation et l’éducation des étudiants du médical et paramédical à propos de la vaccination. Ils représentent les professionnels de demain qui travailleront au sein de nos établissements, ils devraient représenter une population convaincue à la sortie de leurs études et pourtant le constat fait est malheureusement tout autre… Nous ne pouvons que conseiller un meilleur investissement et une plus grande considération des hautes écoles et universités à cet égard.

Au final, différents acteurs s’étaient impliqués dans cette campagne, à différents échelons, et étaient parvenus à placer la grippe et son vaccin au centre des préoccupations.

A travers cet article je souhaite donc vous rassurer et vous confirmer que majorer le taux de personnel vacciné est possible, à condition d’y croire et de pouvoir déployer l’énergie nécessaire à cette fin. L’an passé, au C.H.M., nous avons dépassé le taux de 60% de personnel vacciné (62% précisement), cela sans miracle mais en essayant d’impliquer et de fédérer le plus de personnes possibles autour de l’objectif santé que l’on s’était fixé ensemble. Cette campagne-là n’a plus été la seule préoccupation des hygiénistes, elle est devenue un projet institutionnel. Il a fallu convaincre ! Et c’est ensemble que nous avons pu franchir cette première étape.

Un nouveau challenge s’offre alors à nous à présent, celui de pérenniser ce taux évidemment mais, pourquoi pas, de le faire grimper à nouveau cette saison à venir ?

En toute modestie je souhaite que mon partage d’expérience puisse contribuer, un peu, à l’amélioration de votre taux de vaccination et que vous puissiez trouver quels leviers vous aideront à y parvenir.

Reférences

(1) BRAGARD, C., GOUBAU, P., MAHILLON, J., MICHIELS, Th., (s.d.). Initiation à la virologie. Document non publié. UCLouvain. En ligne : https://www.virologie-uclouvain.be/fr/chapitres/exemples-choisis/virus-de-la-grippe.

(2) FOURMANOIR, P., (2018). Connaissances, perceptions et attitudes du personnel de santé du Centre Hospitalier de Mouscron vis-à-vis de la vaccination contre la grippe saisonnière.  Mémoire. Université Catholique de Louvain.

(3) GREEN, L.W., and KREUTER, M.W., (1991). Health Promotion Planning: an educational and environmental approach. Mayfield edition. 2d edition.

(4) LEHMANN, B. A., CHAPMAN, G. B., FRANSSEN, F. M. E., KOK, G., et RUITER, R. A. C., (2016). Changing the default to promote influenza vaccination among health care workers. Vaccine, 34(11), 1389-1392. doi:https://doi.org/10.1016/j.vaccine.2016.01.046

(5) LEROY, R., (2008). Influence d’une campagne de sensibilisation sur la motivation à accepter ou refuser la vaccination contre la grippe en milieu hospitalier. Mémoire. Université Catholique de Louvain.

(6) LEVY-BRUHL, D., (2016). Traité de santé publique. Politique vaccinale, P 311-322. Paris: Lavoisier médecine-sciences.

(7) LOCOGE, TH., VAN GEET, CH., (2016). Avis n° 64 du 14 décembre 2015 relatif aux aspects éthiques de l’obligation de vacciner émis par le Comité consultatif de Bioéthique de Belgique. Présentation Assemblée Générale du Conseil Supérieur de la Santé 18/05/2016.

(8) ORGANISATION MONDIALE DE LA SANTE. (2010). Guide de Mise en Œuvre de la Stratégie multimodale de l’OMS pour la Promotion de l’Hygiène des Mains. En ligne : http://apps.who.int/iris/bitstream/handle/10665/70478/WHO_IER_PSP_2009.02_fre.pdf?sequence=1.

(9) ORGANISATION MONDIALE DE LA SANTE, UNICEF, Banque mondiale. (2010). Vaccins et vaccination : la situation dans le monde, 3ème édition, Genève. En ligne : http://apps.who.int/iris/bitstream/10665/44209/1/9789242563863_fre.pdf.

(10) SYDNOR, E., and PERL, T. M., (2014). Healthcare providers as sources of vaccine-preventable diseases. Vaccine, 32(38), 4814-4822. doi:https://doi.org/10.1016/j.vaccine.2014.03.097

Introduction

Les bénéfices de la vaccination antigrippale des travailleurs des soins de santé ne sont plus à démontrer. Non seulement celle-ci permet au travailleur de se protéger contre la grippe mais elle protège également la collectivité permettant ainsi de limiter les épidémies et la transmission nosocomiale.

En 2018, l’équipe de prévention et de contrôle des infections (PCI) des Cliniques Universitaires Saint-Luc (CUSL) a mené une intense campagne de vaccination antigrippale à l’attention des travailleurs des Cliniques. Outre la gratuité du vaccin pour l’ensemble des membres du personnel, un vaste plan de communication a été mis en place. En effet, des informations sur la grippe ainsi que sur le vaccin et les modalités pratiques de vaccination ont été diffusées via de nombreux canaux :
mails, portail intranet des CUSL, fascicules distribués au restaurant du personnel, écrans des CUSL… En parallèle, des petits films de sensibilisation relatant l’importance de la vaccination antigrippale ont été réalisés par des personnalités emblématiques de l’institution.

Durant la période de vaccination, un pin’s a été distribué aux vaccinés, ce pin’s ayant pour but de rassurer les patients pris en charge par le soignant. Un compteur institutionnel affichant le nombre de vaccinés au sein de l’institution a également été mis en place de même qu’un petit concours visant à récompenser l’unité de soins ayant le meilleur taux de vaccination. Enfin, afin de rendre la vaccination la plus accessible possible, les plages de vaccination fixes ont été étendues par rapport aux années précédentes, de nombreuses séances de vaccination itinérante ont été organisées et des vaccins ont été mis en dépôt en plusieurs endroits.

Suite aux efforts déployés par l’équipe PCI (Prévention et Contrôle des Infections), celle-ci a voulu évaluer l’impact de la campagne de vaccination contre la grippe mise sur pieds en 2018. Pour ce faire, un questionnaire a été distribué aux vaccinés afin de connaître les principales motivations à la vaccination antigrippale, les éventuelles raisons de non-vaccination en 2017 et les méthodes de sensibilisation remarquées.

Au total, 1740 (24,8%) membres du personnel et 102 bénévoles ont été vaccinés. Les infirmiers, avec 25,1% de vaccinés, représentent la catégorie professionnelle ayant la meilleure couverture vaccinale. Une seule unité de soins, à savoir l’unité de gastro-entérologie pédiatrique, affiche un taux de vaccination supérieur à 50%, toutes professions confondues. La protection des patients semble être la principale motivation des travailleurs à la vaccination. Concernant les principales raisons de non-vaccination en 2017, les vaccinés 2018 rapportent le fait de ne pas être présents lors des séances de vaccination, le manque de temps et le manque de conviction par rapport au vaccin. Un peu moins de 20% des répondants ont déclaré avoir été sensibilisés par la campagne et le fascicule distribué au restaurant du personnel contenant un vrai/faux sur la grippe. Des informations pratiques sur l’organisation de la vaccination semble être la méthode de sensibilisation la plus remarquée, suivie de la diffusion de ces mêmes informations par mail et des films de sensibilisation.

Malgré les efforts menés par l’institution, le taux de vaccination antigrippal des travailleurs aux CUSL reste insuffisant. On note toutefois une hausse d’environ 6% par rapport à l’année 2017. Dans le but d’améliorer encore davantage la couverture vaccinale des travailleurs, l’équipe PCI envisage pour les années futures de réitérer les actions menées en 2018 mais également d’implémenter d’autres stratégies telles que par exemple l’implication des patients dans la campagne de vaccination antigrippale et l’élargissement de l’accessibilité à la vaccination pour tous les acteurs des soins de santé.

Introduction   

La grippe saisonnière est une infection virale aigüe provoquée par des virus Influenza de type A et de type B. Parmi ces deux types, on distingue plusieurs sous-types qui sont chaque année à l’origine d’épidémies. (1)

Les symptômes de la grippe peuvent varier de modérés à très graves. Les principaux symptômes sont fièvre, douleurs musculaires, toux, autres problèmes respiratoires et mal-être général. Sans complications, les symptômes peuvent durer en moyenne pendant 3 à 7 jours, même si la toux et le mal-être général peuvent persister jusqu’à deux semaines. (2)

Les complications touchent surtout les personnes âgées. Plus de 95 % des personnes qui décèdent de la grippe sont âgées de 65 ans ou plus. (3) Les nourrissons et les personnes ayant une comorbidité ont également plus de risques de souffrir de complications. Les plus fréquentes sont la bronchite et l’infection pulmonaire chez les adultes et l’otite moyenne chez les enfants. D’autres complications peuvent également se manifester, comme myosite, myocardite, péricardite, syndrome du choc toxique et syndrome de Reye (chez les enfants sous thérapie à l’aspirine). Des complications peuvent directement être provoquées par le virus Influenza, mais l’infection avec le virus de la grippe facilite également les surinfections bactériennes avec notamment Streptococcus pneumoniae et Staphylococcus aureus. (4) 

La vaccination est la mesure la plus efficace pour prévenir la grippe (1). Le Conseil Supérieur de la Santé recommande non seulement la vaccination contre la grippe aux personnes présentant un risque accru de complications mais aussi aux personnes actives dans le secteur de la santé. (5) Les professionnels de la santé constituent en effet la principale source de contamination de patients pendant une épidémie nosocomiale (6). Vu que 30 à 50 % des infections par le virus Influenza sont asymptomatiques (7) et que la grippe est déjà contagieuse avant même l’apparition des premiers symptômes, les professionnels de la santé peuvent involontairement devenir une source d’infection. Les personnes âgées et patients qui séjournent dans un institut de soins sont souvent plus sujets à la grippe et aux complications inhérentes que les jeunes adultes en bonne santé. L’affaiblissement de l’immunité avec l’avancée en âge ou à cause d’une maladie ou d’immunosuppresseurs rend le vaccin contre la grippe en outre souvent moins efficace chez ces personnes que chez des adultes sains. Il est dès lors vivement recommandé que les professionnels de la santé se fassent vacciner afin de ne pas devenir un vecteur du virus et d’ éviter de contaminer les personnes à risque. (1)

Problématique

Au sein de l’ OLV Ziekenhuis Aalst-Asse-Ninove, le taux de vaccination des professionnels de la santé était historiquement bas et oscillait aux alentours de 30 %. Afin de mieux protéger les patients vulnérables de l’hôpital, il a été décidé en 2017 de fixer un objectif d’accroissement du taux de vaccination des collaborateurs de l’ OLV afin que d’ici la saison hivernale 2018-2019, un taux de vaccination contre la grippe de 65 % soit atteint.

Jusqu’à la saison hivernale 2016-2017, la vaccination contre la grippe était proposée aux collaborateurs moyennant une inscription préalable auprès du service médecine du travail au mois de septembre. Les vaccins trivalents étaient administrés entre octobre et novembre par les médecins du travail dans le local de consultation du service médecine du travail, et ce, pendant les pauses ou en combinaison avec l’examen médical périodique. Chaque année, l’importance de la vaccination contre la grippe a été expliquée à l’automne par un médecin du travail lors d’une réunion avec les infirmiers en chef et les dates des moments de vaccination étaient communiquées par le biais de l’infolettre interne de l’OLV.

Méthode

Depuis la saison hivernale 2017-2018, la campagne de vaccination contre la grippe pour les professionnels de la santé de l’OLV Ziekenhuis a été organisée différemment, à l’aide d’un manuel pour hôpitaux mis au point par la Vlaams Agentschap Zorg & Gezondheid (8) :

– L’organisation de la campagne de vaccination contre la grippe a été prise en charge par une équipe multidisciplinaire, au sein de laquelle sont représentés le service médecine du travail, le service de prévention et protection au travail, la pharmacie, le service du personnel, le département de soins, le département facilitaire, le service de communication, la direction et l’équipe opérationnelle en hygiène hospitalière et épidémiologie.

– La vaccination contre la grippe a été rendue accessible. Aucune inscription préalable n’était nécessaire et l’administration des vaccins a été rapprochée des collaborateurs. En marge des moments de vaccination dans le local de consultation du service médecine du travail, des moments de vaccination ont également été organisés à proximité du restaurant du personnel et lors des réunions de travail des unités de soins. Les vaccins ont été administrés par un ou plusieurs membres de l’équipe de vaccination, composée de médecins du travail, de quelques infirmiers du département de soins et de l’ensemble de l’équipe opérationnelle en hygiène hospitalière et épidémiologie.

– La sensibilisation des collaborateurs et médecins a été stimulée par la promotion de la vaccination des collaborateurs au sein de leur propre département. 

– Depuis la saison hivernale 2018-2019, un vaccin contre la grippe tétravalent est administré, conformément à l’avis du Conseil supérieur de la Santé.

– L’importance de la vaccination contre la grippe a fait l’objet d’une vaste promotion avant la saison hivernale 2018-2019, par le biais notamment d’une campagne organisée dans l’hôpital (voir illustration 1), soutenue par des dépliants, des posters, des messages dans l’infolettre interne de l’OLV, une page dédiée à la vaccination contre la grippe sur l’intranet et une vidéo de promotion interne.

– Le taux de vaccination contre la grippe de l’hôpital a été communiqué chaque semaine de la saison hivernale 2018-2019 par le biais de l’infolettre interne de l’OLV et par le biais du baromètre de la grippe (voir illustration 2) sur la page d’accueil de l’intranet.

– Pendant la saison hivernale 2018-2019, il a également été fait appel à des incitants : tous les collaborateurs vaccinés ont reçu un badge portant la mention « je suis vacciné pour vous ».
Cent trente tickets de cinéma ont également été offerts par tirage au sort aux professionnels de la santé vaccinés. Pour terminer, un budget de teambuilding de 25 euros par professionnel de la santé vacciné a été offert aux unités atteignant un taux de vaccination de 80 % ou plus.

– À l’issue de la campagne de vaccination 2018-2019, la campagne a été évaluée à l’aide d’un questionnaire électronique structuré anonyme. Ce questionnaire s’adressait à tous les professionnels de la santé (vaccinés ou non).

Illustration 1 : l’équipe de distribution des dépliants circule dans l’hôpital 

Illustration 2 : Représentation graphique de l’évolution du taux de vaccination de la grippe pendant la campagne

Résultats

Après la campagne de vaccination contre la grippe 2017-2018, un taux de vaccination de 45 % avait été atteint parmi les professionnels de la santé de l’OLV. Ce qui représente une hausse de 13 pourcents par rapport aux années précédentes. Après la campagne de vaccination contre la grippe 2018-2019, un taux de vaccination de 65 % a été atteint parmi les professionnels de la santé de l’OLV, soit une progression de 20 pourcents (voir graphique 1).

Graphique 1 : Évolution du taux de vaccination contre la grippe des professionnels de la santé au sein de l’OLV Ziekenhuis.

Même si l’objectif d’un taux de vaccination de 65 % des professionnels de la santé de l’OLV a été atteint pendant la saison hivernale 2018-2019, on remarque d’importantes disparités entre les unités. Au sein du département de soins, le taux de vaccination par unité fluctue entre 24 et 100 %, 15 des 70 unités (21 %) atteignant un taux de vaccination contre la grippe de moins de 50 %. 

L’enquête d’évaluation de la campagne de vaccination contre la grippe a été complétée par 1 276 collaborateurs de la santé, dont 1 033 vaccinés (ce qui correspond à 59 % du nombre total de professionnels de la santé vaccinés). Voici quelques tendances qui se dégagent de ce questionnaire :

– Les principales raisons justifiant une non-vaccination sont le fait que la vaccination n’est pas perçue comme une plus-value (30 %) et des mauvaises expériences avec la vaccination par le passé vécues par la personne proprement dite (22 %) ou une de ses connaissances (20 %).

– Parmi les personnes interrogées vaccinées, 137 se faisaient vacciner pour la première fois. La motivation la plus fréquemment citée était la protection de soi et de la famille (51%) et des patients (45%). Le fait que des informations préalables ont été obtenues à propos de l’utilité de la vaccination a été cité par 27 % de ces personnes interrogées comme raison de leur vaccination, ainsi que le souhait de protéger les collègues. Le budget promis pour le teambuilding a motivé 26 % des personnes interrogées à se faire vacciner pour la première fois.

– Le nombre de moments de vaccination a été perçu comme suffisant par 99 % des personnes interrogées qui se sont faites vacciner. 

– La majorité des personnes interrogées vaccinées se sont faites vacciner au sein de leur propre département propre (41 %) ou pendant un moment de vaccination central (40 %). Un nombre restreint s’est fait vacciner pendant une réunion de travail (8,5 %), pendant une consultation auprès du service médecine du travail (6 %) ou auprès de leur médecin généraliste propre (2 %).

– Les personnes vaccinées ont été interrogées à propos de leur intention de se faire vacciner lors de la prochaine saison hivernale : 94 % envisagent de se faire à nouveau vacciner lors de la prochaine saison hivernale, 1 % ne le fera pas et 5 % hésitent encore. Le doute ou le refus de se refaire vacciner à l’avenir est principalement motivé par l’apparition de réactions cutanées locales ou d’un sentiment de mal-être général après la vaccination.

– Pour une prochaine campagne de sensibilisation sur la vaccination contre la grippe, les méthodes de sensibilisation suivantes sont considérées comme les plus pertinentes par les personnes interrogées vaccinées : messages dans l’infolettre du OLV (69 %), campagne à l’aide de dépliants (54 %) et évolution du taux de vaccination sur l’intranet (46 %).

Conclusion

La vaccination des professionnels de la santé contribue à la protection des patients contre la grippe et les complications inhérentes. Une campagne de vaccination à l’échelle de l’hôpital (basée sur le manuel de la « Vlaams Agentschap Zorg & Gezondheid ») a contribué en 2 ans à un doublement du taux de vaccination des professionnels de la santé. Le taux de vaccination contre la grippe au sein du département de soins varie cependant fortement d’une unité à l’autre. À l’avenir, des efforts supplémentaires devront être entrepris au sein des unités présentant un taux de vaccination inférieur pour éliminer les préjugés, parfois tenaces, sur la vaccination contre la grippe. L’attitude des responsables est également importante pour convaincre les collaborateurs (modèle).

Remerciements     

Les auteurs remercient toute personne ayant contribué de manière directe ou indirecte à la réalisation et à la réussite de ce projet. Ils remercient tout particulièrement le service médecine du travail Liantis, la direction ml de l’OLV Ziekenhuis, le service communication, la pharmacie, les médecins et infirmiers ayant administré les vaccins contre la grippe, tout membre de l’équipe de distribution des dépliants ou ayant fait d’une autre façon la promotion de la vaccination contre la grippe auprès de ses collègues, le service du personnel, le service TIC et, enfin et surtout, tous les professionnels de la santé qui se sont faits vacciner.

Références

1. Agentschap Zorg & Gezondheid. Seizoensgriepvaccinatie van gezondheidswerkers. Wetenschappelijk dossier/ 31.05.2017.

2. Carrat F, Vergu E, Ferguson NM, Lemaitre M, Cauchemez S, Leach S, et al. Time lines of infection and disease in human influenza: a review of volunteer challenge studies. Am J Epidemiol. 2008;167(7):775-85.

3. Hanquet G, Jonckheer P, Vlayen J, Vrijens F, Thiry N, Beutels P. Vaccinatie tegen seizoensinfluenza:prioritaire doelgroepen – Deel I.  Good Clinical Practice (GCP). Brussels: Federaal Kenniscentrum voor de Gezondheidszorg; 2011.  Contract No.: D/2011/10.273/43.

4. Joseph C, Togawa Y, Shindo N. Bacterial and viral infections associated with influenza. Influenza Other Respir Viruses. 2013;7 Suppl 2:105-13.

5. Hoge Gezondheidsraad. Vaccinatie tegen seizoensgebonden griep – winterseizoen 2018-2019, maart 2018 (HGR NR 9488).

6. Salgado CD, Farr BM, Hall KK, Hayden FG. Influenza in the acute hospital setting. Lancet Infect Dis. 2002;2(3):145-55.

7. Hopman CE, Riphagen-Dalhuisen J, Looijmans-van den Akker I, Frijstein G, Van der Geest-Blankert AD, Danhof-Pont MB, et al. Determination of factors required to increase uptake of influenza vaccination among hospital-based healthcare workers. J Hosp Infect. 2011;77(4):327-31.

8. Agentschap Zorg & Gezondheid. Organisatie van een seizoensgriepcampagne. Handleiding voor ziekenhuizen / 31.05.2017.

Epidemiol Infect. 2019 Jan;147:e185. doi: 10.1017/S0950268819000748.

Social patterning of acute respiratory illnesses in the Household Influenza Vaccine Evaluation (HIVE) Study 2014-2015.

Malosh RE, Noppert GA, Zelner J, Martin ET, Monto AS.

Abstract

Patterning of infectious diseases is increasingly recognised. Previous studies of social determinants of acute respiratory illness (ARI) have found that highly educated and lower income families experience more illnesses. Subjective social status (SSS) has also been linked to symptomatic ARI, but the association may be confounded by household composition. We examined SSS and ARI in the Household Influenza Vaccine Evaluation (HIVE) Study in 2014-2015. We used SSS as a marker of social disadvantage and created a workplace disadvantage score for working adults. We examined the association between these measures and ARI incidence using mixed-effects Poisson regression models with random intercepts to account for household clustering. In univariate analyses, mean ARI was higher among children <5 years old (P < 0.001), and females (P = 0.004) at the individual level. At the household level, mean ARI was higher for households with at least one child <5 years than for those without (P = 0.002). In adjusted models, individuals in the lowest tertile of SSS had borderline significantly higher rates of ARI than those in the highest tertile (incidence rate ratio (IRR) 1.34, 95% confidence interval (CI) 0.98-1.92). Households in the lowest tertile of SSS had significantly higher ARI incidence in household-level models (IRR 1.46, 95% CI 1.05-2.03). We observed no association between workplace disadvantage and ARI. We detected an increase in the incidence of ARI for households with low SSS compared with those with high SSS, suggesting that socio-economic position has a meaningful impact on ARI incidence.

Epidemiol Infect. 2019 Jan;147:e163. doi: 10.1017/S0950268819000542.  

Developing influenza and respiratory syncytial virus activity thresholds for syndromic surveillance in England.

Harcourt SE, Morbey RA, Smith GE, Loveridge P, Green HK, Pebody R, Rutter J, Yeates FA, Stuttard G, Elliot AJ. 

Abstract

Influenza and respiratory syncytial virus (RSV) are common causes of respiratory tract infections and place a burden on health services each winter. Systems to describe the timing and intensity of such activity will improve the public health response and deployment of interventions to these pressures. Here we develop early warning and activity intensity thresholds for monitoring influenza and RSV using two novel data sources: general practitioner out-of-hours consultations (GP OOH) and telehealth calls (NHS 111). Moving Epidemic Method (MEM) thresholds were developed for winter 2017-2018. The NHS 111 cold/flu threshold was breached several weeks in advance of other systems. The NHS 111 RSV epidemic threshold was breached in week 41, in advance of RSV laboratory reporting. Combining the use of MEM thresholds with daily monitoring of NHS 111 and GP OOH syndromic surveillance systems provides the potential to alert to threshold breaches in real-time. An advantage of using thresholds across different health systems is the ability to capture a range of healthcare-seeking behaviour, which may reflect differences in disease severity. This study also provides a quantifiable measure of seasonal RSV activity, which contributes to our understanding of RSV activity in advance of the potential introduction of new RSV vaccines.

Hum Vaccin Immunother. 2019 May 7:1-6. doi: 10.1080/21645515.2019.1599678. [Epub ahead of print]

Influenza vaccination coverage among splenectomized patients: an Italian study on the role of active recall in the vaccination compliance.

Bianchi FP, Rizzo LA, De Nitto S, Stefanizzi P, Tafuri S.

Abstract

Patients with anatomical or functional hypo-/a-splenia have a 10- to 50-fold higher risk of developing severe infectious diseases than does the general population. Thus, it is recommended to adhere to a specific vaccination schedule, including receiving influenza vaccine. During 2014, Bari Policlinico General Hospital approved a specific protocol to ensure that vaccines are actively offered to all splenectomized patients during their hospitalizations. The aim of this study is to evaluate the efficacy of this active recall protocol for performing influenza vaccination in the years following splenectomy among patients still involved in a specific vaccination program carried out by the hospital’s Hygiene department. From May 2014 to October 2016, 96 patients were involved in the vaccination program of the Hygiene department. In November 2017, 46/96 (48%) of patients received a specific invitation by phone to receive the annual influenza vaccine (intervention group), while 50/96 (52%) did not receive any such invitation (control group). At the end of the 2017 influenza season, 73/96 (76%; 95%CI = 66-84%) of patients reported having received the influenza vaccine; no differences were observed in the extent of vaccine coverage between the groups (intervention group = 80% vs. control group = 72%; p = 0.33). Older age, more recent splenectomy, hemo-lymphopathy and receiving the previous years’ doses of influenza vaccine are associated with receiving influenza vaccination during the 2017 season. These data indicate how effective communication at the time of the vaccine counseling results in good adherence to the vaccination program even after several years. Indeed, vaccination should be an opportunity not only limited to the administration of the vaccine but also for providing patient care.

J Infect Dis. 2019 May 6. pii: jiz212. doi: 10.1093/infdis/jiz212. [Epub ahead of print]

Infant pneumococcal carriage during influenza, RSV and hMPV respiratory illness within a maternal influenza immunization trial.

Murray AF, Englund JA, Kuypers J, Tielsch JM, Katz J, Khatry SK, Leclerq SC, Chu HY.

Abstract

In this post-hoc analysis of nasopharyngeal pneumococcal carriage in a community-based, randomized prenatal influenza vaccination trial in Nepal with weekly infant respiratory illness surveillance, 457 of 605 (75.5%) infants with influenza, RSV or hMPV illness had pneumococcus detected. Pneumococcal carriage did not impact rates of lower respiratory tract disease for these three viruses. Influenza-positive infants born to mothers given influenza vaccine had lower pneumococcal carriage rates compared to infants born to placebo mothers (58.1% versus 71.6%, p=0.03). No difference was observed in RSV- or hMPV-infected infants (p=0.94, 0.11). Maternal influenza immunization may impact infant acquisition of pneumococcus during influenza infection.

© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America.

Eur J Public Health. 2019 May 5. pii: ckz074. doi: 10.1093/eurpub/ckz074. [Epub ahead of print] 

Cost-effectiveness of public health interventions against human influenza pandemics in France: a methodological contribution from the FLURESP European Commission project.

Beresniak A, Rizzo C, Oxford J, Gorynski P, Pistol A, Fabiani M, Napoli C, Barral M, Niddam L, Bounekkar A, Bonnevay S, Lionis C, Gauci C, Bremond D.

Abstract
Background: 

The FLURESP project is a public health project funded by the European Commission with the objective to design a methodological approach in order to compare the cost-effectiveness of existing public health measures against human influenza pandemics in four target countries: France, Italy, Poland and Romania. This article presents the results relevant to the French health system using a data set specifically collected for this purpose.

Methods: 
Eighteen public health interventions against human influenza pandemics were selected. Additionally, two public-health criteria were considered: ‘achieving mortality reduction ≥40%’ and ‘achieving morbidity reduction ≥30%’. Costs and effectiveness data sources include existing reports, publications and expert opinions. Cost distributions were taken into account using a uniform distribution, according to the French health system.

Result: 
Using reduction of mortality as an effectiveness criterion, the most cost-effective options was ‘implementation of new equipment of Extracorporeal membrane oxygenation (ECMO) equipment’. Targeting vaccination to health professionals appeared more cost-effective than vaccination programs targeting at risk populations. Concerning antiviral distribution programs, curative programs appeared more cost-effective than preventive programs. Using reduction of morbidity as effectiveness criterion, the most cost-effective option was ‘implementation of new equipment ECMO’. Vaccination programs targeting the general population appeared more cost-effective than both vaccination programs of health professionals or at-risk populations. Curative antiviral programs appeared more cost-effective than preventive distribution programs, whatever the pandemic scenario.

Conclusions: 
Intervention strategies against human influenza pandemics impose a substantial economic burden, suggesting a need to develop public-health cost-effectiveness assessments across countries.

J Infect Dis. 2019 May 3. pii: jiz201. doi: 10.1093/infdis/jiz201. [Epub ahead of print]

Birth Cohort Effects in Influenza Surveillance Data: Evidence that First Influenza Infection Affects Later Influenza-Associated Illness.

Budd AP, Beacham L, Smith CB, Garten RJ, Reed C, Kniss K, Mustaquim D, Ahmad FB, Cummings CN, Garg S, Levine MZ, Fry AM, Brammer L.

Abstract 
Background: 
The evolution of influenza A viruses results in birth cohorts that have different initial influenza virus exposures. Historically, A/H3 predominant seasons have been associated with more severe influenza-associated disease; however, since the 2009 pandemic there are suggestions that some birth cohorts experience more severe illness in A/H1 predominant seasons.

Methods:
U.S. influenza virologic, hospitalization and mortality surveillance data during 2000-2017 were analyzed for cohorts born between 1918 and 1989 that likely had different initial influenza virus exposures based on viruses circulating during early childhood. Relative risk/rate during H3 compared to H1 predominant seasons during pre-pandemic versus pandemic and later periods were calculated for each cohort.

Results: 
During the pre-pandemic period, all cohorts had more influenza-associated disease during H3 predominant seasons than H1 predominant seasons. During the pandemic and later period, four cohorts had higher hospitalization and mortality rates during H1 predominant seasons than H3 predominant seasons.

Discussion: 
Birth cohort differences in risk of influenza-associated disease by influenza A virus subtype can be seen in U.S. influenza surveillance data and differ between pre-pandemic and pandemic and later periods. As the population ages, the amount of influenza-associated disease may be greater in future H1 predominant seasons than H3 predominant seasons.

Published by Oxford University Press for the Infectious Diseases Society of America 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Int J Infect Dis. 2019 Apr 30. pii: S1201-9712(19)30194-8. doi: 10.1016/j.ijid.2019.04.023. [Epub ahead of print]

MF59-Adjuvanted Seasonal Trivalent Inactivated Influenza Vaccine: Safety and Immunogenicity in Young Children at Risk of Influenza Complications.

Patel SS, Bizjajeva S, Heijnen E, Oberye J.

Abstract

Objective: 
To assess safety and immunogenicity of the MF59®-adjuvanted seasonal trivalent inactivated influenza vaccine (aIIV3; Fluad™) in children aged 6 months through 5 years who are at risk of influenza complications.

Methods: 
A retrospective analysis was performed to examine unsolicited adverse events (AEs) in an integrated data set from 6 randomized clinical studies that compared aIIV3 with nonadjuvanted inactivated influenza vaccines (IIV3). The integrated safety set comprised of 10,784 children, of which 373 (3%) were at risk of influenza complications.

Results:  
The at-risk safety population comprised 373 children 6 months through 5 years of age: 179 received aIIV3 and 194 received nonadjuvanted IIV3 (128 subjects received a licensed IIV3). The most important risk factors were include respiratory system illnesses (62% to 70%), or infectious and parasitic diseases (33% to 39%). During the treatment period, unsolicited AEs occurred in 54% of at-risk children and 55% of healthy children who received aIIV3; of those receiving licensed IIV3, 59% of at-risk and 62% of healthy subjects reported an unsolicited AE. The most common AEs were infections, including upper respiratory tract infection. Serious AEs (SAEs) were reported in <10% of at-risk subjects, and no vaccine-related SAEs were observed. In the immunogenicity subset (involving 103 participants from 1 study), geometric mean titers (GMTs) were approximately 2- to 3-fold higher with aIIV3 than with IIV3 for all 3 homologous strains (A/H1N1, A/H3N2, and B). Seroconversion rates were high for both aIIV3 (79% to 96%) and IIV3 (83% to 89%).

Conclusion: 
In young children at risk of influenza complications, aIIV3 was well-tolerated and had a safety profile that was generally similar to that of nonadjuvanted IIV3. Similar to the not-at risk population, the immune response in at-risk subjects receiving aIIV3 was increased over those receiving IIV3, suggesting aIIV3 is a valuable option in young children at risk of influenza complications.

Copyright © 2019. Published by Elsevier Ltd.

Epidemics. 2019 Apr 18. pii: S1755-4365(18)30140-3. doi: 10.1016/j.epidem.2019.04.001. [Epub ahead of print]

Real-time prediction of influenza outbreaks in Belgium.

Miranda GHB, Baetens JM, Bossuyt N, Bruno OM, De Baets B.

Abstract
Seasonal influenza is a worldwide public health concern. Forecasting its dynamics can improve the management of public health regulations, resources and infrastructure, and eventually reduce mortality and the costs induced by influenza-related absenteism. In Belgium, a network of Sentinel General Practitioners (SGPs) is in place for the early detection of the seasonal influenza epidemic. This surveillance network reports the weekly incidence of influenza-like illness (ILI) cases, which makes it possible to detect the epidemic onset, as well as other characteristics of the epidemic season. In this paper, we present an approach for predicting the weekly ILI incidence in real-time by resorting to a dynamically calibrated compartmental model, which furthermore takes into account the dynamics of other influenza seasons. In order to validate the proposed approach, we used data collected by the Belgian SGPs for the influenza seasons 2010-2016. In spite of the great variability among different epidemic seasons, providing weekly predictions makes it possible to capture variations in the ILI incidence. The confidence region becomes more representative of the epidemic behavior as ILI data from more seasons become available. Since the SIR model is then calibrated dynamically every week, the predicted ILI curve gets rapidly tuned to the dynamics of the ongoing season. The results show that the proposed method can be used to characterize the overall behavior of an epidemic.

Copyright © 2019. Published by Elsevier B.V.

Vaccine. 2019 Apr 29. pii: S0264-410X(19)30525-0. doi: 10.1016/j.vaccine.2019.04.051. [Epub ahead of print]

Impact of influenza vaccination on healthcare utilization – A systematic review.

Doyon-Plourde P, Fakih I, Tadount F, Fortin É, Quach  C.

Abstract
Introduction: 
Although a vaccine-preventable disease, influenza causes approximately 3-5 million cases of severe illness and about 290,000-650,000 deaths worldwide, which occur primarily among people 65 years and older. Nonetheless, prevention of influenza and its complications rely mainly on vaccination. We aimed to systematically evaluate influenza vaccine effectiveness at reducing healthcare utilization in older adults, defined as the reduction of outpatient visits, ILI and influenza hospitalizations, utilization of antibiotics and cardiovascular events by vaccination status during the influenza season.

Methods: 
We searched MEDLINE, EMBASE, CINAHL, Cochrane Library and considered any seasonal influenza vaccine, excluding the pandemic (2009-10 season) vaccine. Reviewers independently assessed data extraction and quality assessment.

Results: 
Of the 8308 citations retrieved, 22 studies were included in the systematic review. Overall, two studies (9%) were deemed at moderate risk of bias, thirteen (59%) at serious risk of bias and seven (32%) at critical risk of bias. For outpatient visits, we found modest evidence of protection by the influenza vaccine. For all-cause hospitalization outcomes, we found a wide range of results, mostly deemed at serious risk of bias. The included studies suggested that the vaccine may protect older adults against influenza hospitalizations and cardiovascular events. No article meeting our inclusion criteria explored the use of antibiotics and ILI hospitalizations. The high heterogeneity between studies hindered the aggregation of data into a meta-analysis.

Conclusion: 
The variability between studies prevented us from drawing a clear conclusion on the effectiveness of the influenza vaccine on healthcare utilization in older adults. Overall, the data suggests that the vaccine may result in a reduction of healthcare utilization in the older population. Further studies of higher quality are necessary.

Paediatr Child Health. 2018 Dec;23(8):565-566. doi: 10.1093/pch/pxy150. Epub 2018 Nov 19.

Vaccine recommendations for children and youth for the 2018/2019 influenza season.

Moore DL.

Abstract 
The Canadian Paediatric Society continues to encourage annual influenza vaccination for all children and youth ≥6 months of age. Recommendations from the National Advisory Committee on Immunization (NACI) for the 2018/2019 influenza season are not substantially changed from those of last season. Quadrivalent vaccine, if available, is recommended for children 6 months to 17 years of age. Either inactivated influenza vaccine or live attenuated influenza vaccine may be used for children and youth 2 to 17 years of age who are not immunocompromised.

J Prev Med Hyg. 2019 Mar 29;60(1):E64-E67. doi: 10.15167/2421-4248/jpmh2019.60.1.1205. eCollection 2019 Mar. 

The Spanish Influenza Pandemic: a lesson from history 100 years after 1918.

Martini M, Gazzaniga V, Bragazzi NL, Barberis I.

Abstract
In Europe in 1918, influenza spread through Spain, France, Great Britain and Italy, causing havoc with military operations during the First World War. The influenza pandemic of 1918 killed more than 50 million people worldwide. In addition, its socioeconomic consequences were huge. «Spanish flu», as the infection was dubbed, hit different age-groups, displaying a so-called «W-trend», typically with two spikes in children and the elderly. However, healthy young adults were also affected. In order to avoid alarming the public, several local health authorities refused to reveal the numbers of people affected and deaths. Consequently, it was very difficult to assess the impact of the disease at the time. Although official communications issued by health authorities worldwide expressed certainty about the etiology of the infection, in laboratories it was not always possible to isolate the famous Pfeiffer’s bacillus, which was, at that time, deemed to be the cause of influenza. The first official preventive actions were implemented in August 1918; these included the obligatory notification of suspected cases and the surveillance of communities such as day-schools, boarding schools and barracks. Identifying suspected cases through surveillance, and voluntary and/or mandatory quarantine or isolation, enabled the spread of Spanish flu to be curbed. At that time, these public health measures were the only effective weapons against the disease, as no vaccines or antivirals were available. Virological and bacteriological analysis of preserved samples from infected soldiers and other young people who died during the pandemic period is a major step toward a better understanding of this pandemic and of how to prepare for future pandemics.

Nurs Clin North Am. 2019 Jun;54(2):227-243. doi: 10.1016/j.cnur.2019.02.009.

Seasonal Influenza (Flu).

Keilman LJ.

Abstract 

Seasonal influenza, or flu, is an airborne respiratory virus that occurs every year in the fall to early spring in the United States. The virus is highly contagious and symptoms can run from mild to severe. In some populations (very young, individuals with chronic comorbid conditions, immunocompromised individuals of all ages, pregnant women, and frail older adults), the virus can lead to increased morbidity and mortality. In a majority of cases, seasonal influenza is preventable through safe and readily available vaccinations.

Can Commun Dis Rep. 2019 Jan 3;45(1):12-23. doi: 10.14745/ccdr.v45i01a02. eCollection 2019 Jan 3.

Effectiveness of hand hygiene practices in preventing influenza virus infection in the community setting: A systematic review.

Moncion K, Young K, Tunis M, Rempel S, Stirling R, Zhao L.  

Background:
Hand hygiene is known to be an effective infection prevention and control measure in health care settings. However, the effectiveness of hand hygiene practices in preventing influenza infection and transmission in the community setting is not clear.

Objective:
To identify, review and synthesize available evidence on the effectiveness of hand hygiene in preventing laboratory-confirmed or possible influenza infection and transmission in the community setting.

Methods:
A systematic review protocol was established prior to conducting the review. Three electronic databases (MEDLINE, Embase and the Cochrane Library) were searched to identify relevant studies. Two reviewers independently screened the titles, abstracts and full-texts of studies retrieved from the database searches for potential eligibility. Data extraction and quality assessment of included studies were performed by a single reviewer and validated by a second reviewer. Included studies were synthesized and analyzed narratively.

Results: 
A total of 16 studies were included for review. Studies were of low methodological quality and there was high variability in study design, setting, context and outcome measures. Nine studies evaluated the effectiveness of hand hygiene interventions or practices in preventing laboratory-confirmed or possible influenza infection in the community setting; six studies showed a significant difference, three studies did not. Seven studies assessed the effectiveness of hand hygiene practices in preventing laboratory-confirmed or possible influenza transmission in the community setting; two studies found a significant difference and five studies did not.

Conclusion: 
The effectiveness of hand hygiene against influenza virus infection and transmission in the community setting is difficult to determine based on the available evidence. In light of its proven effectiveness in other settings, there is no compelling evidence to stop using good hand hygiene practice to reduce the risk of influenza infection and transmission in the community setting.

Neth J Med. 2019 Apr;77(3):109-115.

Implementation of point-of-care testing and a temporary influenza ward in a Dutch hospital.

Lankelma JM, Hermans MHA, Hazenberg EHLCM, Macken T, Dautzenberg PLJ, Koeijvoets KCMC, Jaspers JWH, van Gageldonk-Lafeber AB, Lutgens SPM. 

Abstract 
Background
The seasonal influenza epidemic poses a significant burden on hospitals, both in terms of capacity and costs. Beds that are occupied by isolated influenza patients result in hospitals temporary being closed to admissions and elective operations being cancelled. Improving hospital and emergency department (ED) patient flow during the influenza season could solve these problems. Microbiological point-of-care-testing (POCT) could reduce unnecessary patient isolation by providing a positive/negative result before admission, but has not yet broadly been implemented.

Methods:
A clinical pathway for patients with acute respiratory tract infection presenting at the ED was implemented, including a PCR-based POCT for influenza, operated by nurses and receptionists. In parallel, a temporary ward equipped with 15 beds for influenza-positive patients was established. In this retrospective observational study, we describe the results of implementing this pathway by comparison with the previous epidemic.

Results:
Clinical performance of the POCT within the clinical pathway was good with strongly decreased time from ED presentation to sample collection (194 vs 47 min) and time from sample collection to result (1094 vs 62 min). Hospital patient flow was improved by a decreased percentage of admitted influenza-positive patients (91% vs 73%) and shorter length of subsequent stay (median 5.86 vs 4.61 days) compared to the previous influenza epidemic. In addition, 430 patient-days of unnecessary isolation have been prevented within a time span of 18 weeks. Roughly estimated savings were almost 400,000 euros.

Conclusions
We recommend that hospitals explore possibilities for improving patient flow during an influenza epidemic.

Public Health. 2019 Mar 19;170:17-22. doi: 10.1016/j.puhe.2019.02.006. [Epub ahead of print]

Studying the influence of mass media and environmental factors on influenza virus transmission in the US Midwest. 

Niakan Kalhori SR, Ghazisaeedi M, Azizi R, Naserpour A.

Abstract 
Objectives:
Disease burden and high financial cost of seasonal influenza emphasize the importance of studying the epidemics transmission dynamics. Our aim in this article is to extend the Susceptible Exposed Infectious Recovered (SEIR) model, a well-studied classical compartmental epidemic model, by incorporating socio-environmental factors. Particularly, the potential influence of mass media function and absolute humidity are examined on the model simultaneously.

Study design:
The proposed model is fitted to Center for Disease Control and Prevention (CDC) influenza data of region five of the US for four outbreak seasons. Then, a full-performance comparison between the conventional and extended model is carried out.

Methods:
Implementing the mass media and climate factors into the classical epidemic models, e.g., Susceptible Infectious Recovered (SIR) and SEIR, is a promising and ongoing research field in the public health area. In this article, we particularly address the potential effect of mass media and absolute humidity to modify the SEIR model.

Results:
Computational simulations are carried out for both standard and extended models for four influenza seasons in CDC region five of the US. Moreover, the accuracy assessment is performed based on the following criteria: i) the root mean square error (RMSE); ii) the Akaike information criterion (AIC); iii) the outbreak peak time; and iv) the number of infected individuals at the peak time. Based on these criteria, the proposed model provided a better fit than a null model with smaller RMSE and AIC values for the last three study seasons. Specifically, RMSE values declined from 20 to 11.08 and from 26.87 to 19.15 for seasons 2010/11 and 2011/12, respectively; also, lower AIC values for these seasons indicate that the modified SEIR (referred to M-SEIR) model is a better-fitting model.

Conclusions
Parameter estimation techniques are important tools to determine the key parameters of the epidemic models. Based on our results, introducing the mass media and climate factors into the classic models will improve the model precision.

Copyright © 2019 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Am J Epidemiol. 2015 Aug 15;182(4):294-301. doi: 10.1093/aje/kwv054. Epub 2015 Jul 18.

Hospitalization Fatality Risk of Influenza A(H1N1)pdm09: A Systematic Review and Meta-Analysis.

Wong JY, Kelly H, Cheung CM, Shiu EY, Wu P, Ni MY, Ip DK, Cowling BJ.

Abstract
During the 2009 influenza pandemic, uncertainty surrounding the severity of human infections with the influenza A(H1N1)pdm09 virus hindered the calibration of the early public health response. The case fatality risk was widely used to assess severity, but another underexplored and potentially more immediate measure is the hospitalization fatality risk (HFR), defined as the probability of death among H1N1pdm09 cases who required hospitalization for medical reasons. In this review, we searched for relevant studies published in MEDLINE (PubMed) and EMBASE between April 1, 2009, and January 9, 2014. Crude estimates of the HFR ranged from 0% to 52%, with higher estimates from tertiary-care referral hospitals in countries with a lower gross domestic product, but in wealthy countries the estimate was 1%-3% in all settings. Point estimates increased substantially with age and with lower gross domestic product. Early in the next pandemic, estimation of a standardized HFR may provide a picture of the severity of infection, particularly if it is presented in comparison with a similarly standardized HFR for seasonal influenza in the same setting.

Am J Infect Control. 2016 May 2;44(5 Suppl):e91-e100. doi: 10.1016/j.ajic.2015.11.018.

Emerging infectious diseases: Focus on infection control issues for novel coronaviruses (Severe Acute Respiratory Syndrome-CoV and Middle East Respiratory Syndrome-CoV), hemorrhagic fever viruses (Lassa and Ebola), and highly pathogenic avian influenza viruses, A(H5N1) and A(H7N9). 

Weber DJ, Rutala WA, Fischer WA, Kanamori H, Sickbert-Bennett EE.

Abstract
Over the past several decades, we have witnessed the emergence of many new infectious agents, some of which are major public threats. New and emerging infectious diseases which are both transmissible from patient-to-patient and virulent with a high mortality include novel coronaviruses (SARS-CoV, MERS-CV), hemorrhagic fever viruses (Lassa, Ebola), and highly pathogenic avian influenza A viruses, A(H5N1) and A(H7N9). All healthcare facilities need to have policies and plans in place for early identification of patients with a highly communicable diseases which are highly virulent, ability to immediately isolate such patients, and provide proper management (e.g., training and availability of personal protective equipment) to prevent transmission to healthcare personnel, other patients and visitors to the healthcare facility.

Am J Manag Care. 2015 Jul 1;21(7):e405-13.

Effectiveness and cost of influenza vaccine reminders for adults with asthma or chronic obstructive pulmonary disease.

Shoup JA, Madrid C, Koehler C, Lamb C, Ellis J, Ritzwoller DP, Daley MF.

Abstract
OBJECTIVES: 
To assess the effectiveness and cost of interactive voice response (IVR) reminders for influenza vaccination compared with postcards, among adults with asthma or chronic obstructive pulmonary disease (COPD).

STUDY DESIGN: 

Pragmatic, 3-arm, randomized control trial.

METHODS: 
The trial was conducted in an integrated healthcare organization during 2012 and 2013, using an existing IVR system. All adults aged 19 through 64 years with asthma or COPD (n = 12,285) were randomized to receive 1 of the following vaccination reminders: 1) postcard reminder only, 2) IVR reminder only, or 3) postcard plus IVR reminder. The primary outcome was influenza vaccination by October 31, 2012; the secondary outcomes were influenza vaccination by December 31, 2012, and by March 31, 2013.

RESULTS: 
For subjects receiving an IVR call, 57% received a message on their answering machine; 27% answered the call; and 16% were not reached. Influenza vaccination rates were 29.5%, 31.1%, and 30.6% in the postcard-only, IVR-only, and postcard-plus-IVR study arms, respectively. After controlling for relevant covariates, IVR reminders were not significantly more or less effective than postcard reminders. Program costs were $0.78, $1.23, and $1.93 per subject for postcard-only, IVR-only, and postcard-plus-IVR reminders, respectively. Extrapolating costs to the entire population at the study site that typically receives influenza vaccination reminders (approximately 100,000 individuals), reminder costs would have been $0.55, $0.05, and $0.60 per subject for postcard-only, IVR-only, and postcard-plus-IVR reminders, respectively.

CONCLUSIONS: 
IVR reminders are not more effective at promoting influenza vaccination than postcard reminders, but IVR reminders may be less expensive for large patient populations.

Am J Prev Med. 2015 Dec;49(6 Suppl 4):S355-63. doi: 10.1016/j.amepre.2015.09.012.

Prospects for Broadly Protective Influenza Vaccines.

Treanor JJ.

Abstract
The development of vaccines that could provide broad protection against antigenically variant influenza viruses has long been the ultimate prize in influenza research. Recent developments have pushed us closer to this goal, and such vaccines may now be within reach. This brief review outlines the current approaches to broadly protective vaccines, and the probable hurdles and roadblocks to achieving this goal.

Am J Prev Med. 2015 Apr;48(4):392-401. doi: 10.1016/j.amepre.2014.10.023.

Impacting delayed pediatric influenza vaccination: a randomized controlled trial of text message reminders.

Hofstetter AM, Vargas CY, Camargo S, Holleran S, Vawdrey DK, Kharbanda EO, Stockwell MS.

Abstract
BACKGROUND: 
Influenza vaccination coverage is low, especially among low-income populations. Most doses are generally administered early in the influenza season, yet sustained vaccination efforts are crucial for achieving optimal coverage. The impact of text message influenza vaccination reminders was recently demonstrated in a low-income population. Little is known about their effect on children with delayed influenza vaccination or the most effective message type.

PURPOSE: 
To determine the impact of educational plus interactive text message reminders on influenza vaccination of urban low-income children unvaccinated by late fall.

DESIGN: 
Randomized controlled trial.

SETTING/PARTICIPANTS: 
Parents of 5,462 children aged 6 months-17 years from four academically affiliated pediatric clinics who were unvaccinated by mid-November 2011.

INTERVENTION: 
Eligible parents were stratified by their child’s age and pediatric clinic site and randomized using a 1:1:1 allocation to educational plus interactive text message reminders, educational-only text message reminders, or usual care. Using an immunization registry-linked text messaging system, parents of intervention children received up to seven weekly text message reminders. One of the messages sent to parents in the educational plus interactive text message arm allowed selection of more information about influenza and influenza vaccination.

MAIN OUTCOME MEASURES: 
Influenza vaccination by March 31, 2012. Data were collected and analyzed between 2012 and 2014.

RESULTS: 
Most children were publicly insured and Spanish speaking. Baseline demographics were similar between groups. More children of parents in the educational plus interactive text message arm were vaccinated (38.5%) versus those in the educational-only text message (35.3%; difference=3.3%, 95% CI=0.02%, 6.5%; relative risk ratio (RRR)=1.09, 95% CI=1.002, 1.19) and usual care (34.8%; difference=3.8%, 95% CI=0.6%, 7.0%; RRR=1.11, 95% CI=1.02-1.21) arms.

CONCLUSIONS: 
Text message reminders with embedded educational information and options for interactivity have a small positive effect on influenza vaccination of urban, low-income, minority children who remain unvaccinated by late fall.

Am J Prev Med. 2014 Sep;47(3):330-40. doi: 10.1016/j.amepre.2014.05.035.

A systematic review of mandatory influenza vaccination in healthcare personnel.

Pitts SI, Maruthur NM, Millar KR, Perl TM, Segal J.

Abstract
CONTEXT: 
Influenza is a major cause of patient morbidity. Mandatory influenza vaccination of healthcare personnel (HCP) is increasingly common yet has uncertain clinical impact. This study systematically examines published evidence of the benefits and harm of influenza vaccine mandates.

EVIDENCE ACQUISITION: 
MEDLINE, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index Expanded, and Conference Proceedings Citations Index were searched and analyzed in 2013. Studies must have assessed the effect of a requirement of influenza vaccination among HCP for continued employment or clinical practice. Studies were not limited by comparison group, outcome, language, or study design. Two reviewers independently abstracted data and assessed bias risk.

EVIDENCE SYNTHESIS: 
Twelve observational studies were included in the study from 778 citations. Following implementation of a vaccine mandate, vaccination rates increased in all eight studies reporting this outcome, exceeding 94%. Three studies documented increased vaccination rates in hospitals with mandates compared to those without (p<0.001 for all comparisons). Two single-institution studies reported limited, inconclusive results on absenteeism among HCP. No studies reported on clinical outcomes among patients. Medical and religious exemptions and terminations or voluntary resignations were rare.

CONCLUSIONS: 
Evidence from observational studies suggests that a vaccine mandate increases vaccination rates, but evidence on clinical outcomes is lacking. Although challenging, large healthcare employers planning to implement a mandate should develop a strategy to evaluate HCP and patient outcomes. Further studies documenting the impact of HCP influenza vaccination on clinical outcomes would inform decisions on the use of mandatory vaccine policies in HCP.

Clin Lab Med. 2014 Jun;34(2):409-30. doi: 10.1016/j.cll.2014.02.011. Epub 2014 Apr 13.

Emerging respiratory viruses other than influenza.

Dunn JJ, Miller MB.

Abstract
Non-influenza respiratory virus infections are common worldwide and contribute to morbidity and mortality in all age groups. The recently identified Middle East respiratory syndrome coronavirus has been associated with rapidly progressive pneumonia and high mortality rate. Adenovirus 14 has been increasingly recognized in severe acute respiratory illness in both military and civilian individuals. Rhinovirus C and human bocavirus type 1 have been commonly detected in infants and young children with respiratory tract infection and studies have shown a positive correlation between respiratory illness and high viral loads, mono-infection, viremia, and/or serologically-confirmed primary infection.

J Clin Nurs. 2016 Oct;25(19-20):2730-44. doi: 10.1111/jocn.13243. Epub 2016 May 21.

Nurses’ knowledge, attitudes and practices regarding influenza vaccination: an integrative review.

Smith S, Sim J, Halcomb E.

Abstract
AIMS AND OBJECTIVES: 
To critically analyse the literature describing nurses’ knowledge, attitudes and practices regarding influenza vaccination.

BACKGROUND: 
Influenza is a serious illness that has significant impacts on productivity, health outcomes and healthcare costs. Despite the recommendations for nurses to be vaccinated annually against influenza, the vaccination rates remain suboptimal.

DESIGN: 
Integrative literature review.

METHODS: 
An integrative review was conducted as described by Whittemore and Knafl (2005). A search of CINAHL, Cochrane Library, ProQuest Central, ClinicalKey, ScienceDirect, Wiley Online Library, and Informit was undertaken to identify relevant papers. Given the heterogeneity of included studies, a narrative approach was used to analyse the data.

RESULTS: 
There was limited research available on this topic area, with only 10 papers identified as meeting the inclusion criteria. Five themes were identified: the relationship between knowledge and influenza vaccination, perception of risk, motivators for influenza vaccination, barriers to influenza vaccination and impact of demographics on vaccination.

CONCLUSIONS: 
Despite the evidence for the protective effects of influenza vaccination, rates of vaccination among nurses remain sub-optimal. Nurses’ influenza vaccination practices likely relate to their level of knowledge and perception of risk; the greater nurses’ knowledge regarding influenza and influenza vaccination the higher their perception of risk and the more likely they are to be vaccinated. This also translates to the advice that they give patients with vaccinated nurses more inclined to recommend vaccination than those unvaccinated.

RELEVANCE TO CLINICAL PRACTICE: 
The practices of nurses related to influenza vaccination may translate to the advice that they give their patients. Understanding the knowledge levels, practices and attitudes of nurses can assist in developing strategies to enhance education of nurses.

J Hosp Infect. 2016 Oct;94(2):133-42. doi: 10.1016/j.jhin.2016.07.003. Epub 2016 Jul 18.

Increasing the coverage of influenza vaccination in healthcare workers: review of challenges and solutions.

To KW, Lai A, Lee KC, Koh D, Lee SS.

Abstract
Seasonal influenza vaccine uptake rate of healthcare workers (HCWs) varies widely from <5% to >90% worldwide. Perception of vaccine efficacy and side-effects are conventional factors affecting the uptake rates. These factors may operate on a personal and social level, impacting the attitudes and behaviours of HCWs. Vaccination rates were also under the influence of the occurrence of other non-seasonal influenza pandemics such as avian influenza. Different strategies have been implemented to improve vaccine uptake, with important ones including the enforcement of the local authority’s recommendations, promulgation of practice guidelines, and mandatory vaccination polices. Practised in some regions in North America, mandatory policies have led to higher vaccination rate, but are not problem-free. The effects of conventional educational programmes and campaigns are in general of modest impact only. Availability of convenient vaccination facilities, such as mobile vaccination cart, and role models of senior HCWs receiving vaccination are among some strategies which have been observed to improve vaccination uptake rate. A multi-faceted approach is thus necessary to persuade HCWs to participate in a vaccination programme, especially in areas with low uptake rate.

J Hosp Infect. 2016 Mar;92(3):235-50. doi: 10.1016/j.jhin.2015.08.027. Epub 2015 Oct 3.

Transmission of SARS and MERS coronaviruses and influenza virus in healthcare settings: the possible role of dry surface contamination.

Otter JA, Donskey C, Yezli S, Douthwaite S, Goldenberg SD, Weber DJ.

Abstract
Viruses with pandemic potential including H1N1, H5N1, and H5N7 influenza viruses, and severe acute respiratory syndrome (SARS)/Middle East respiratory syndrome (MERS) coronaviruses (CoV) have emerged in recent years. SARS-CoV, MERS-CoV, and influenza virus can survive on surfaces for extended periods, sometimes up to months. Factors influencing the survival of these viruses on surfaces include: strain variation, titre, surface type, suspending medium, mode of deposition, temperature and relative humidity, and the method used to determine the viability of the virus. Environmental sampling has identified contamination in field-settings with SARS-CoV and influenza virus, although the frequent use of molecular detection methods may not necessarily represent the presence of viable virus. The importance of indirect contact transmission (involving contamination of inanimate surfaces) is uncertain compared with other transmission routes, principally direct contact transmission (independent of surface contamination), droplet, and airborne routes. However, influenza virus and SARS-CoV may be shed into the environment and be transferred from environmental surfaces to hands of patients and healthcare providers. Emerging data suggest that MERS-CoV also shares these properties. Once contaminated from the environment, hands can then initiate self-inoculation of mucous membranes of the nose, eyes or mouth. Mathematical and animal models, and intervention studies suggest that contact transmission is the most important route in some scenarios. Infection prevention and control implications include the need for hand hygiene and personal protective equipment to minimize self-contamination and to protect against inoculation of mucosal surfaces and the respiratory tract, and enhanced surface cleaning and disinfection in healthcare settings.

J Hosp Infect. 2015 Apr;89(4):314-8. doi: 10.1016/j.jhin.2014.12.017. Epub 2015 Jan 24.

Rapid bedside tests for diagnosis, management, and prevention of nosocomial influenza.

Bouscambert M, Valette M, Lina B.

Abstract
Like other respiratory viruses, influenza is responsible for devastating nosocomial epidemics in nursing homes as well as in conventional wards and emergency departments. Patients, healthcare workers, and visitors may be the source of nosocomial influenza. Despite their limited sensitivity, rapid diagnostic tests for influenza can be of real value; they enable early introduction of measures to prevent spread and early specific antiviral treatment of cases. However, these tests cannot detect oseltamivir resistance, susceptibility testing being carried out only in specialist laboratories. Although resistance is rare, it can emerge during treatment, especially of very young children or immunocompromised patients. In the latter, the shedding of resistant influenza virus can last several weeks. Sporadic instances of nosocomial transmission among immunocompromised patients have been reported. The limitations of bedside tests for influenza make them unsuitable for use as stand-alone diagnostic tools. However, their limitations do not preclude their use for detection and subsequent management of nosocomial influenza, for which they are rapid, easy, and cost-effective. Recent developments in these tests look promising, offering prospects of increased sensitivity, increased specificity, and screening for antiviral susceptibility.

American Journal of Infection Control, Volume 46, Issue 11, November 2018, Pages 1311-1314

Hand hygiene adherence in relation to influenza season during 6 consecutive years

Rosamaria Fulchini, Philipp Kohler,  Christian R. Kahlert, Werner C. Albrich, Matthias Schlegel

Hand hygiene (HH) is the single most important measure in reducing the burden of healthcare-acquired infections. Based on 12,740 HH opportunities observed during 6 consecutive years at our tertiary care center, HH adherence among healthcare workers (HCWs) was significantly better during influenza season compared to non-influenza periods, after controlling for important covariables (odds ratio = 1.17, 95% confidence interval 1.05-1.30). This finding suggests that HH awareness is increased during influenza periods, which could have implications for HCW education.

American Journal of Infection Control, Volume 46, Issue 11, November 2018, Pages 1278-1283

Influenza vaccine coverage and predictive factors associated with influenza vaccine uptake among pediatric patients

Celeste L. Y. Ewig, Ka Ming Tang, Ting Fan Leung, Joyce H. S. You

Background
Despite recommendations from health care authorities, reports of severe influenza occur yearly among unvaccinated infants and children.

Objectives
This study investigated influenza vaccine coverage and predictive factors for vaccination status among pediatric patients during the 2016-2017 winter influenza season.

Methods
A cross-sectional survey was conducted among parents of our study population identified through a major pediatric outpatient clinic in Hong Kong. Parents with a child aged 6 months to 17 years were invited to complete a questionnaire that assessed the current influenza vaccine status of the child and the parents’ understanding and beliefs regarding influenza and its vaccine. A backward logistic regression was conducted to determine predictive factors and adjusted odds ratios associated with influenza vaccine uptake.

Results
Our study included 348 parents and 405 pediatric patients. Of these, 142 pediatric patients (35.1%) received full vaccination. Predictive factors associated with the child’s positive influenza vaccine status include a “very good” parental understanding of influenza and its vaccine (adjusted odds ratio, 6.7; 95% confidence interval,  2.1-21.5), a child with chronic medical condition and a “high” cue to action (adjusted odds ratio, 5.7; 95% confidence interval, 2.8-11.6), and a “high” perceived susceptibility toward influenza (adjusted odds ratio, 4.8; 95% confidence interval, 2.1-10.8).

Conclusions

This study reflects the low influenza vaccine coverage among pediatric patients. Interventions focusing on parental knowledge and understanding of influenza and its vaccine may improve future vaccine uptake among the pediatric population.

American Journal of Infection Control, Volume 44, Issue 10, 1October 2016, Pages 1084-1088

Reasons for influenza vaccination underutilization: A case-control study

Scott S. Field

Background 
Influenza vaccines are underused.

Methods
Most (131/140) patients from a pediatric practice who were tested for influenza in the 2012-2013 season were enrolled. Medical records plus questionnaires determined vaccine and past disease histories and influenza vaccine attitudes. Influenza-negative tested cases (n = 65) and negative controls (n = 110) closely age-matched to 55 test-positive cases were compared with influenza-positive cases (n = 66) regarding prior influenza, vaccine efficacy, and limited vaccine season conflicting with birth dates and preventative visit timing to determine possible validity of reasons given for underutilization.

Results
The most common parental reason for not vaccinating was lack of perceived need. History of previous influenza was significantly (P < .0001) associated with disease. Live attenuated vaccine rates were greater in controls than in influenza patients for ages 2-18 years (P < .005) and for ages 6-18 years (P < .0001), whereas injectable vaccine rates were not  (P = .30 and P = .60, respectively). Most positive cases (59%) and controls (89%) had no prior influenza.

Conclusions
Prior influenza disease may be a risk factor for infection that could influence vaccination benefit. Live attenuated influenza vaccine outperformed trivalent inactivated influenza vaccine. Limited disease experience in individuals with low influenza vaccination rates, along with vaccine efficacy limitations, lends validity to some underutilization.

American Journal of Infection Control, Volume 44, Issue 3, 1 March 2016, Pages 361-362

Barriers of influenza vaccination in health care personnel in France

Zoher Kadi, Mohamed-Lamine Atif, Annie Brenet, Sylvain Izoard, Pascal Astagneau

To identify barriers against influenza vaccination of health care personnel in Northern France, a cross-sectional study was conducted in health care facilities. A total of 3,213 questionnaires from 67 health care facilities were completed. In multivariate analysis using a logistic model, influenza vaccine coverage in health care personnel was significantly associated with level of knowledge about influenza disease and vaccine

American Journal of Infection Control, Volume 45, Issue 11, 1 November 2017, Pages 1243-1248

Workplace interventions associated with influenza vaccination coverage among health care personnel in ambulatory care settings during the 2013-2014 and 2014-2015 influenza seasons

Xin Yue, Carla Black, Sarah Ball, Sara Donahue, Stacie Greby

Background
Vaccination of health care personnel (HCP) can reduce influenza-related morbidity and mortality among HCP and their patients. This study investigated workplace policies associated with influenza vaccination among HCP who work in ambulatory care settings without influenza vaccination requirements.

Methods
Data were obtained from online surveys conducted during April 2014 and April 2015 among nonprobability samples of HCP recruited from 2 preexisting national opt-in Internet panels. Respondents were asked about their vaccination status and workplace policies and interventions related to vaccination. Logistic regression models were used to assess the independent associations between each workplace intervention and influenza vaccination while controlling for occupation, age, and race or ethnicity.

Results
Among HCP working in ambulatory care settings without a vaccination requirement (n = 866), 65.7% reported receiving influenza vaccination for the previous influenza season. Increased vaccination coverage was independently associated with free onsite vaccination for 1 day (prevalence ratio [PR], 1.38; 95% confidence interval [CI], 1.07-1.78 or >1 day PR, 1.58; 95% CI, 1.29-1.94) and employers sending personal vaccination reminders (PR, 1.20; 95% CI, 0.99-1.46). Age ≥65 years (PR, 1.30; 95% CI, 1.07-1.56) and working as a clinical professional (PR, 1.26; 95% CI, 1.06-1.50) or clinical nonprofessional (PR, 1.28; 95% CI, 1.03-1.60) were also associated with higher coverage. Vaccination coverage increased with increasing numbers of workplace interventions.

Conclusions
Implementing workplace vaccination interventions in ambulatory care settings, including free onsite influenza vaccination that is actively promoted, could help increase influenza vaccination among HCP.

American Journal of Infection Control, Volume 45, Issue 6, 1 June 2017, Pages 635-641

Stepwise intervention including 1-on-1 counseling is highly effective in increasing influenza vaccination among health care workers

Younghee Jung, Mihye Kwon, Jeongmi Song

Background
The influenza vaccination rate among health care workers (HCWs) remains suboptimal. We attempted to increase vaccine uptake in HCWs by nonmandatory measures, including 1-on-1 counseling.

Methods
In 2015 we used a stepwise approach including (1) text messaging on the last day of the vaccination period, (2) extending the vaccination period by 3 days, (3) education for the low uptake group, and (4) 1-on-1 counseling for unvaccinated HCWs after the 3 interventions.

Results
There were 1,433 HCWs included. By the end of the initial 3 days, the uptake rate was 80.0% (1,146/1,433). During an extension for a further 3 days, 33 additional HCWs received the vaccine. One month after starting the vaccination, 90.1% (1,291/1,433) of the HCWs were vaccinated, but this included only 76.1% (210/276) of the doctors (lowest among HCWs). After 3 educational presentations targeted at the unvaccinated doctors, no additional individuals were vaccinated in the following 2 weeks. After 1-on-1 counseling for unvaccinated HCWs, the overall vaccination rate increased to 94.7% (1,357/1,433) in 2015, higher than in the previous year (82.5%, P < .001). Of the unvaccinated doctors, 63.2% (43/68) were vaccinated, therefore achieving 92.4% (255/276) compliance, higher than the 56.5% in the previous year (152/269, P < .001).

Conclusions
Stepwise intervention including 1-on-1 counseling is effective in increasing influenza vaccination rates among HCWs.

American Journal of Infection Control, Volume 45, Issue 11, 1 November 2017, Pages 1249-1253

Outbreaks of health care–associated influenza-like illness in France: Impact of electronic notification

Elodie Munier-Marion, Thomas Bénet, Cédric Dananché, Sophan Soing-Altach, Philippe Vanhems

Background
Mandatory notification of health care–associated (HA) infections, including influenza-like illness (ILI) outbreaks, has been implemented in France since 2001. In 2012, the system moved to online electronic notification of HA infections (e-SIN). The objectives of this study are to describe ILI outbreak notifications to Santé publique France (SPF), the French national public health agency, and to evaluate the impact of notification dematerialization.

Methods
All notifications of HA ILI outbreaks between July 2001 and June 2015 were included. Notifications before and after e-SIN implementation were compared regarding notification delay and information exhaustiveness.

Results
Overall, 506 HA ILI outbreaks were reported, accounting for 7,861 patients and health care professionals. Median delay between occurrence of the first case and notification was, respectively, 32 and 13 days before and after e-SIN utilization (P < .001). Information exhaustiveness was improved by electronic notification regarding HA status (8.5% of missing data before and 2.3% after e-SIN, P = .003), hypotheses of cause (25.4% of missing data before vs 8.0% after e-SIN, P < .001), and level of event control (23.7% of missing data before vs 7.5% after e-SIN, P < .001).

Conclusions
HA influenza notifications, including HA ILI or influenza, to health authorities are essential to guide decisional instances and health care practices. Electronic notifications have improved the timeliness and quality of information transmitted.

Journal of Hospital Infection, Volume 94, Issue 2, October 2016, Pages 133-142

Increasing the coverage of influenza vaccination in healthcare workers: review of challenges and solutions

K. W. To, A. Lai, K. C. K. Lee, D. Koh, S. S. Lee

Summary
Seasonal influenza vaccine uptake rate of healthcare workers (HCWs) varies widely from <5% to >90% worldwide. Perception of vaccine efficacy and side-effects are conventional factors affecting the uptake rates. These factors may operate on a personal and social level, impacting the attitudes and behaviours of HCWs. Vaccination rates were also under the influence of the occurrence of other non-seasonal influenza pandemics such as avian influenza. Different strategies have been implemented to improve vaccine uptake, with important ones including the enforcement of the local authority’s recommendations, promulgation of practice guidelines, and mandatory vaccination polices. Practised in some regions in North America, mandatory policies have led to higher vaccination rate, but are not problem-free. The effects of conventional educational programmes and campaigns are in general of modest impact only. Availability of convenient vaccination facilities, such as mobile vaccination cart, and role models of senior HCWs receiving vaccination are among some strategies which have been observed to improve vaccination uptake rate. A multi-faceted approach is thus necessary to persuade HCWs to participate in a vaccination programme, especially in areas with low uptake rate.

Journal of Hospital Infection, Volume 79, Issue 4, December 2011, Pages 279-286

Effectiveness of seasonal influenza vaccination in healthcare workers: a systematic review

A. N. M. Ng, C. K. Y. Lai

Summary
Vaccination is considered a key measure to protect vulnerable groups against influenza infection. The objectives of this review are to determine the effect of influenza vaccinations in reducing laboratory-confirmed influenza infections, influenza-like illnesses (ILIs), working days lost among vaccinated HCWs, and associated adverse effects after vaccination. Twenty-two healthcare-related databases and internet resources, as well as reference lists, and the bibliographies of all of the retrieved articles were examined. All randomized controlled trials (RCTs) comparing the effectiveness of any kind of influenza vaccine among all groups of HCWs with a placebo/vaccine other than the influenza vaccine/no intervention were included in the review. Only three RCTs matched the inclusion criteria. There is a limited amount of evidence suggesting that receiving influenza vaccination reduces laboratory-confirmed influenza infections in HCWs. No evidence can be found of influenza vaccinations significantly reducing the incidence of influenza, number of ILI episodes, days with ILI symptoms, or amount of sick leave taken among vaccinated HCWs. There is insufficient data to assess the adverse effects after vaccination. There is no definitive conclusion on the effectiveness of influenza vaccinations in HCWs because of the limited number of related trials. Further research is necessary to evaluate whether annual vaccination is a key measure to protect HCWs against influenza infection and thus increase their confidence in the vaccine. In the mean time, the direction of promoting influenza vaccination to HCWs can be shifted from staff protection to patient protection, with accurate information to address concerns and misconceptions.