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1.  The 2009 pandemic H1N1 influenza vaccination in France: who accepted to receive the vaccine and why? 
PLoS Currents  2010;2:RRN1188.
Introduction: Previous studies investigating determinants of 2009 (H1N1) pandemic influenza vaccine acceptance have focused on target groups such as healthcare workers. Few studies in the European Union have examined the self-reported reasons as well as predictive socio-demographic and health factors for pandemic influenza vaccine acceptance in the general population, even though influenza vaccine was recommended for all people.
Methods: A nationwide telephone survey was conducted in France during the peak of the outbreak that occurred in December 2009 in adults (≥ 16 years), using a proportional random-digit dialing.
Results: Interviews were completed by 1003 individuals, of whom 275 (27.4%) either had received pandemic influenza vaccine during the last weeks or intended to get vaccinated in the next weeks. Acceptance rates of pandemic vaccine were significantly higher among men, more educated and wealthier people, as well as persons who had a prior experience of influenza vaccination. The patterns of self-reported reasons for vaccine acceptance could be broadly divided into 3 groups related to (1) the mental representation of the threat – in particular the beliefs associated with the severity and personal vulnerability to the illness, (2) the perception of efficacy and safety of the vaccine, and (3) trust/distrust toward those advocating the vaccine.
Conclusions: This national study indicates that social and cognitive determinants of pandemic influenza vaccine acceptance among French adults were relatively similar to those identified by previous studies of acceptance of seasonal influenza vaccine.
PMCID: PMC2957695  PMID: 20972476
2.  Influenza vaccine uptake among community-dwelling Italian elderly: results from a large cross-sectional study 
BMC Public Health  2011;11:207.
Flu vaccination significantly reduces the risk of serious complications like hospitalization and death among community-dwelling older people, therefore vaccination programmes targeting this population group represent a common policy in developed Countries. Among the determinants of vaccine uptake in older age, a growing literature suggests that social relations can play a major role.
Drawing on the socio-behavioral model of Andersen-Newman - which distinguishes predictors of health care use in predisposing characteristics, enabling resources and need factors - we analyzed through multilevel regressions the determinants of influenza immunization in a sample of 25,183 elderly reached by a nationally representative Italian survey.
Being over 85-year old (OR = 1.99; 95% CI 1.77 - 2.21) and suffering from a severe chronic disease (OR = 2.06; 95% CI 1.90 - 2.24) are the strongest determinants of vaccine uptake. Being unmarried (OR = 0.81; 95% CI 0.74 - 0.87) and living in larger households (OR = 0.83; 95% CI 0.74 - 0.87) are risk factors for lower immunization rates. Conversely, relying on neighbors' support (OR = 1.09; 95% CI 1.02 - 1.16) or on privately paid home help (OR = 1.19; 95% CI 1.08 - 1.30) is associated with a higher likelihood of vaccine uptake.
Even after adjusting for socio-demographic characteristics and need factors, social support, measured as the availability of assistance from partners, neighbors and home helpers, significantly increases the odds of influenza vaccine use among older Italians.
PMCID: PMC3078885  PMID: 21457562
influenza vaccine; older people; Italy
3.  Determinants of influenza vaccination uptake among Italian healthcare workers 
We analyzed seasonal influenza vaccination coverage among the Italian healthcare workers (HCW) in order to identify socio-demographic and clinical determinants of vaccination.
We used data from the survey “Health and health care use in Italy,” which comprised interviews of 5,336 HCWs For each respondent, information on socioeconomic, health conditions, self-perceived health and smoking status were obtained. After bivariate analysis, we used multilevel regression models to assess determinants of immunization. Overall 20.8% of HCWs (95%CI 19.7–21.9) reported being vaccinated against seasonal influenza.
After controlling for potential confounders, multilevel regression revealed that older workers have a higher likelihood of vaccine uptake (OR = 6.07; 95% CI 4.72–7.79). Conversely, higher education was associated with lower vaccine uptake (OR = 0.65; 95% IC 0.50–0.83). Those suffering from diabetes (OR = 2.07; 95% CI 1.19–1.69), COPD (OR = 1.95; 95% CI 1.31–2.89) and cardiovascular diseases (OR = 1.48 95% CI 1.11–1.96) were more likely to be vaccinated. Likewise, smokers, or former smokers receive more frequently the vaccination (OR = 1.40; 95% CI 1.15–1.70; OR = 1.54; 95% CI 1.24–1.91, respectively) compared with never-smokers as well as those HCWs reporting fair or poor perceived health status (ORs of 1.68, 95% CI 1.30–2.18).
Vaccine coverage among HCWs in Italy remains low, especially among those with no comorbidities and being younger than 44 y old. This behavior not only raises questions regarding healthcare organization, infection control in healthcare settings and clinical costs, but also brings up ethical issues concerning physicians who seem not to be very concerned about the impact of the flu on themselves, as well as on their patients. Influenza vaccination campaigns will only be effective if HCWs understand their role in influenza transmission and prevention, and realize the importance of vaccination as a preventive measure
PMCID: PMC3903913  PMID: 24064543
administration and dosage; attitude of health personnel; health behavior; human prevention and control; influenza; influenza vaccines; socioeconomic factors
4.  Educational Content and the Effectiveness of Influenza Vaccination Reminders 
To determine if a mailed patient education brochure (addressing demonstrated reasons for vaccination refusal) would result in a higher rate of influenza vaccination than a mailed postcard reminder without educational content.
Randomized, controlled trial.
Urban, predominantly African-American, low-income community.
There were 740 community-dwelling individuals aged 65 years and older in the study.
Receipt of influenza vaccination and beliefs about influenza and influenza vaccination were measured by telephone survey self-report.
We successfully contacted 202 individuals (69.9%) who received the postcard reminder and 229 individuals (71.1%) who received the educational brochure. People receiving the educational brochure were more likely to report influenza vaccination during the previous vaccination season than those who received the postcard reminder (66.4% vs 56.9%, p = .04). They also reported more interest in influenza vaccination in the coming year. (66.5% vs 57.1%, p = .05).
A mailed educational brochure is more effective than a simple reminder in increasing influenza vaccination rates among inner-city, elderly patients.
PMCID: PMC1496760  PMID: 10571718
influenza; vaccination; educational reminder; elderly; inner-city population
5.  Risk Perception, Preventive Behaviors, and Vaccination Coverage in the Korean Population during the 2009–2010 Pandemic Influenza A (H1N1): Comparison between High-Risk Group and Non–High-Risk Group 
PLoS ONE  2013;8(5):e64230.
This study was carried out to estimate the vaccination coverage, public perception, and preventive behaviors against pandemic influenza A (H1N1) and to understand the motivation and barriers to vaccination between high-risk and non–high-risk groups during the outbreak of pandemic influenza A (H1N1).
Methodology/Principal Findings
A cross-sectional nationwide telephone survey of 1,650 community-dwelling Korean adults aged 19 years and older was conducted in the later stage of the 2009–2010 pandemic influenza A (H1N1) outbreak. The questionnaire identified the demographics, vaccination status of participants and all household members, barriers to non-vaccination, perceived threat, and preventive behaviors. In Korea, the overall rate of pandemic influenza vaccination coverage in the surveyed population was 15.5%; vaccination coverage in the high-risk group and non–high-risk group was 47.3% and 8.0%, respectively. In the high-risk group, the most important triggering event for vaccination was receiving a notice from a public health organization. In the non–high-risk group, vaccination was more strongly influenced by previous experience with influenza or mass media campaigns. In both groups, the most common reasons for not receiving vaccination was that their health was sufficient to forgo the vaccination, and lack of time. There was no significant difference in how either group perceived the threat or adopted preventive behavior. The predictive factors for pandemic influenza vaccination were being elderly (age ≥65 years), prior seasonal influenza vaccination, and chronic medical disease.
With the exception of vaccination coverage, the preventive behaviors of the high-risk group were not different from those of the non–high-risk group during the 2009–2010 pandemic. For future pandemic preparedness planning, it is crucial to reinforce preventive behaviors to avoid illness before vaccination and to increase vaccination coverage in the high-risk group.
PMCID: PMC3656839  PMID: 23691175
6.  A cross-sectional study of factors associated with uptake of vaccination against influenza among older residents in the postpandemic season in Beijing, China 
BMJ Open  2013;3(11):e003662.
Annually, influenza epidemics are associated with high mortality rates, notably among elderly persons. The aim of the study was to examine the level of influenza vaccine coverage among Chinese residents aged 60 years and older and to examine the demographic, behavioural and lifestyle health factors associated with vaccine receipt.
Cross-sectional study.
Beijing, China.
Stratified sampling was used to recruit participants for this study. A total of 2578 people aged 60 years and older consented to participate in this study. Questionnaires from 2481 participants were valid and were included in the final analysis.
Outcome measures
Influenza vaccination status and factors associated with vaccination.
In late 2010, a survey was conducted with residents from three urban and three rural districts in Beijing, China. Multivariate logistic regression was performed to detect the factors associated with influenza vaccination.
2481 older people (aged ≥60 years) were included in the final analysis. In 2010, 44% had received the annual influenza vaccine. Lower education level, poor health status of the participant, regular taking exercises and considering that vaccine is the best measure for preventing influenza were associated with influenza vaccination coverage.
Influenza vaccine coverage in Beijing still remains suboptimal. Further work needs to be undertaken to ascertain whether the methods used to distribute the vaccine are adequate and whether health professionals are appropriately promoting the vaccine.
PMCID: PMC3840337  PMID: 24259387
7.  Rates of influenza vaccination in older adults and factors associated with vaccine use: A secondary analysis of the Canadian Study of Health and Aging 
BMC Public Health  2004;4:36.
Influenza vaccination has been shown to reduce morbidity and mortality in the older adult population. In Canada, vaccination rates remain suboptimal. We identified factors predictive of influenza vaccination, in order to determine which segments of the older adult population might be targeted to increase coverage in influenza vaccination programs.
The Canadian Study of Health and Aging (CSHA) is a population-based national cohort study of 10263 older adults (≥ 65) conducted in 1991. We used data from the 5007 community-dwelling participants in the CSHA without dementia for whom self-reported influenza vaccination status is known.
Of 5007 respondents, 2763 (55.2%) reported having received an influenza vaccination within the previous 2 years. The largest predictive factors for flu vaccination included: being married (57.4 vs. 52.6%, p = 0.0007), having attained a higher education (11.0 vs. 10.3 years, p < 0.0001), smoking (57.1% vs. 52.9%, p = 0.0032), more alcohol use (57.9% of those who drank more vs. 53.2% of those who drank less, p = 0.001), poorer self-rated health (54.1% of those with good self-rated health vs. 60.6% of those with poor self-rated health, p = 0.0006), regular exercise (56.8% vs. 52.0%, p = 0.001), and urban living (55.8% vs. 51.0%, p = 0.03).
While many other differences were statistically significant, most were small (e.g. mean age 75.1 vs. 74.6 years for immunized vs. unimmunized older adults, p = 0.006, higher Modified Mini Mental Status Examination score (89.9 vs. 89.1, p < 0.0001), higher comorbidity (2.7 vs. 2.3 comorbidities, p < 0.0001).
Residents of Ontario were more likely (64.6%) to report vaccination (p < 0.0001), while those living in Quebec were less likely to do so (48.2%, p < 0.0001). Factors retaining significance in a multivariate analysis included older age, higher education, married status, drinking alcohol, smoking, engaging in regular exercise, and having higher comorbidity.
The vaccination rate in this sample, in whom influenza vaccination is indicated, was low (55.2%). Even in a publicly administered health care setting, influenza vaccination did not reach an important proportion of the elderly population. Whether these differences reflect patient preference or access remains to be determined.
PMCID: PMC514709  PMID: 15306030
8.  Campaign, counseling and compliance with influenza vaccine among older persons 
Clinics  2011;66(12):2031-2035.
Population aging raises concerns regarding the increases in the rates of morbidity and mortality that result from influenza and its complications. Although vaccination is the most important tool for preventing influenza, vaccination program among high-risk groups has not reached its predetermined aims in several settings. This study aimed to evaluate the impacts of clinical and demographic factors on vaccine compliance among the elderly in a setting that includes a well-established annual national influenza vaccination campaign.
This cross-sectional study included 134 elderly patients who were regularly followed in an academic medical institution and who were evaluated for their influenza vaccination uptake within the last five years; in addition, the demographic and clinical characteristics and the reasons for compliance or noncompliance with the vaccination program were investigated.
In total, 67.1% of the participants received the seasonal influenza vaccine in 2009. Within this vaccination-compliant group, the most common reason for vaccine uptake was the annual nationwide campaign (52.2%; 95% CI: 41.4–62.9%); compared to the noncompliant group, a higher percentage of compliant patients had been advised by their physician to take the vaccine (58.9% vs. 34.1%; p<0.01).
The education of patients and health care professionals along with the implementation of immunization campaigns should be evaluated and considered by health authorities as essential for increasing the success rate of influenza vaccination compliance among the elderly.
PMCID: PMC3226596  PMID: 22189726
Influenza immunization; Campaign; Medical recommendation; Adherence; Geriatric
9.  Influenza vaccination coverage across ethnic groups in Canada 
The success of influenza vaccination campaigns may be suboptimal if subgroups of the population face unique barriers or have misconceptions about vaccination. We conducted a national study to estimate influenza vaccine coverage across 12 ethnic groups in Canada to assess the presence of ethnic disparities.
We pooled responses to the Canadian Community Health Survey between 2003 and 2009 (n = 437 488). We estimated ethnicity-specific self-reported influenza vaccine coverage for the overall population, for people aged 65 years and older, and for people aged 12–64 years with and without chronic conditions. We used weighted logistic regression models to examine the association between ethnicity and influenza vaccination, adjusting for sociodemographic factors and health status.
Influenza vaccination coverage ranged from 25% to 41% across ethnic groups. After adjusting for sociodemographic factors and health status for people aged 12 years and older, all ethnic groups were more likely to have received a vaccination against influenza than people who self-identified as white, with the exception of those who self-identified as black (odds ratio [OR] 1.01, 95% confidence interval [CI] 0.88–1.15). Compared with white Canadians, Canadians of Filipino (OR 2.00, 95% CI 1.67–2.40) and Southeast Asian (OR 1.66, 95% CI 1.36–2.03) descent had the greatest likelihood of having received vaccination against influenza.
Influenza vaccine coverage in Canada varies by ethnicity. Black and white Canadians have the lowest uptake of influenza vaccine of the ethnic groups represented in our study. Further research is needed to understand the facilitators, barriers and misconceptions relating to vaccination that exist across ethnic groups, and to identify promotional strategies that may improve uptake among black and white Canadians.
PMCID: PMC3478352  PMID: 22966054
10.  Influenza vaccination coverage rates among adults before and after the 2009 influenza pandemic and the reasons for non-vaccination in Beijing, China: A cross-sectional study 
BMC Public Health  2013;13:636.
To optimize the vaccination coverage rates in the general population, the status of coverage rates and the reasons for non-vaccination need to be understood. Therefore, the objective of this study was to assess the changes in influenza vaccination coverage rates in the general population before and after the 2009 influenza pandemic (2008/2009, 2009/2010, and 2010/2011 seasons), and to determine the reasons for non-vaccination.
In January 2011 we conducted a multi-stage sampling, retrospective, cross-sectional survey of individuals in Beijing who were ≥ 18 years of age using self-administered, anonymous questionnaires. The questionnaire consisted of three sections: demographics (gender, age, educational level, and residential district name); history of influenza vaccination in the 2008/2009, 2009/2010, and 2010/2011 seasons; and reasons for non-vaccination in all three seasons. The main outcome was the vaccination coverage rate and vaccination frequency. Differences among the subgroups were tested using a Pearson’s chi-square test. Multivariate logistic regression was used to determine possible determinants of influenza vaccination uptake.
A total of 13002 respondents completed the questionnaires. The vaccination coverage rates were 16.9% in 2008/2009, 21.8% in 2009/2010, and 16.7% in 2010/2011. Compared to 2008/2009 and 2010/2011, the higher rate in 2009/2010 was statistically significant (χ2=138.96, p<0.001), and no significant difference existed between 2008/2009 and 2010/2011 (χ2=1.296, p=0.255). Overall, 9.4% of the respondents received vaccinations in all three seasons, whereas 70% of the respondents did not get a vaccination during the same period. Based on multivariate analysis, older age and higher level of education were independently associated with increased odds of reporting vaccination in 2009/2010 and 2010/2011. Among participants who reported no influenza vaccinations over the previous three seasons, the most commonly reported reason for non-vaccination was ‘I don’t think I am very likely to catch the flu’ (49.3%).
Within the general population of Beijing the vaccination coverage rates were relatively low and did not change significantly after the influenza pandemic. The perception of not expecting to contract influenza was the predominant barrier to influenza vaccination. Further measures are needed to improve influenza vaccination coverage.
PMCID: PMC3708734  PMID: 23835253
Influenza vaccine; Vaccination; Coverage; Adult
11.  Preventive Care Use among the Belgian Elderly Population: Does Socio-Economic Status Matter? 
Objective: To analyze the association between influenza and pneumococcus vaccination and blood cholesterol and blood sugar measurement by Belgian elderly respondents (≥65 years) and socio-demographic characteristics, risk factors, health status and socio-economic status (SES). Methods: A cross-sectional study based on 4,544 non-institutionalized elderly participants of the Belgian Health Interview Surveys 2004 and 2008. Multivariate logistic regression models were constructed to examine the independent effect of socio-demographic characteristics, risk factors, health status and SES on the four preventive services. Results: After adjustment for age, sex, region, survey year, living situation, risk factors (body mass index, smoking status, physical activity) and health status (self-assessed health and longstanding illness) lower educated elderly were significantly less likely to report a blood cholesterol and blood sugar measurement. For instance, elderly participants with no degree or only primary education were less likely to have had a cholesterol and blood sugar measurement compared with those with higher education. Pneumococcus vaccination was not related to educational level, but lower income groups were more likely to have had a pneumococcus immunization. Influenza vaccination was not significantly related to SES. Conclusion: The results highlight the need to promote cholesterol and blood sugar measurement for lower SE groups, and pneumococcus immunization for the entire elderly population. Influenza immunization seems to be equally spread among different SE groups.
PMCID: PMC3924448  PMID: 24368427
preventive care; socioeconomic status; elderly population; Belgium
12.  Use of preventive care by the working poor in the United States 
Preventive medicine  2006;44(3):254-259.
Examine the association between poverty and preventive care use among older working adults.
Cross-sectional analysis of the pooled 1996, 1998 and 2000 waves of the Health and Retirement Study, a nationally representative sample of older community-dwelling adults, studying self-reported use of cervical, breast, and prostate cancer screening, as well as serum cholesterol screening and influenza vaccination. Adults with incomes within 200% of the federal poverty level were defined as poor.
Among 10,088 older working adults, overall preventive care use ranged from 38% (influenza vaccination) to 76% (breast cancer screening). In unadjusted analyses, the working poor were significantly less likely to receive preventive care. After adjustment for insurance coverage, education, and other socio-demographic characteristics, the working poor remained significantly less likely to receive breast cancer (RR 0.92, 95% CI, 0.86–0.96), prostate cancer (RR 0.89, 95% CI, 0.81–0.97), and cholesterol screening (RR 0.91, 95% CI, 0.86–0.96) than the working non-poor, but were not significantly less likely to receive cervical cancer screening (RR 0.96, 95% CI, 0.90–1.01) or influenza vaccination (RR 0.92, 95% CI, 0.84–1.01).
The older working poor are at modestly increased risk for not receiving preventive care.
PMCID: PMC1810564  PMID: 17196642
Poverty; Socioeconomic factors; Prevention and control; Health promotion; Mass screening/utilization; Health services/utilization; United States
13.  Reasons for and against receiving influenza vaccination in a working age population in Japan: a national cross-sectional study 
BMC Public Health  2013;13:647.
To improve influenza vaccination coverage in the working age population, it is necessary to understand the current status and awareness of influenza vaccination. This study aimed to determine influenza vaccination coverage in Japan and reasons for receiving the vaccine or not.
An anonymous internet-based survey was performed in September 2011. Our target study size was 3,000 participants between 20 and 69 years of age, with approximately 300 men and 300 women in each of five age groups (20–29, 30–39, 40–49, 50–59, and 60–69). We asked the history of influenza vaccine uptake in the previous year, and reasons for having vaccination or not.
There were 3,129 respondents, of whom 24.2% of males and 27.6% of females received influenza vaccination between October 2010 and March 2011. Among those who were vaccinated, the main reasons for receiving the influenza vaccine were “Wanted to avoid becoming infected with influenza virus” (males: 84.0%; females: 82.6%) and “Even if infected with influenza, wanted to prevent the symptoms from becoming serious” (males: 60.7%; females: 66.4%). Among those not vaccinated, the most frequent reasons for not receiving the influenza vaccine included “No time to visit a medical institution” (males: 32.0%; females: 22.4%) and “Unlikely to become infected with influenza” (males: 25.1%; females: 22.7%).
The reasons for receiving the influenza vaccine varied between age groups and between sexes. To heighten awareness of influenza vaccination among unvaccinated working age participants, different intervention approaches according to sex and age group may be necessary.
PMCID: PMC3718666  PMID: 23849209
Influenza vaccination; Attitude; General population; Japan
14.  Do People Who Intend to Get a Flu Shot Actually Get One? 
Journal of General Internal Medicine  2009;24(12):1311-1313.
Vaccination against seasonal influenza is far from universal among groups specifically recommended for vaccine. There is little research to guide communication with patients about vaccination.
To assess the utility of the self-reported intention to be vaccinated against seasonal influenza in predicting vaccine uptake, reasons for being unvaccinated, and willingness to be vaccinated based on a doctor’s recommendation.
We analyzed data from a subset of respondents (n = 1,527) specifically recommended by the ACIP for vaccination against seasonal influenza who participated in two national surveys of adults age 18 and older conducted in November 2008 and March 2009.
Over half who intended to be vaccinated had been vaccinated. Compared to those without intentions, those with intentions were one-fifth as likely (p < 0.01) to cite lack of need and five times more likely (p < 0.01) to cite “not getting around to being vaccinated” as main reasons for not being vaccinated. Roughly two-fifths of those without the intention to be vaccinated indicated a willingness to be vaccinated based on a doctor’s recommendation.
Asking simple questions about the intention to be vaccinated against seasonal influenza may be an efficient means of identifying patients with whom extended discussion of vaccine benefits is warranted.
PMCID: PMC2787941  PMID: 19838758
flu vaccination; self-reported intentions; study
15.  Influenza Vaccination of Persons with Cardiovascular Disease in the United States 
Texas Heart Institute Journal  2004;31(1):22-27.
People who have cardiovascular disease are at increased risk of hospitalization or death associated with influenza infection, and are included among the high-risk groups for whom annual influenza vaccination is recommended. To measure the progress toward the national year 2000 and 2010 objectives of a 60% annual influenza vaccination of adults with high-risk conditions aged 18 to 64 years, we analyzed data from the 1997 to 2001 National Health Interview Surveys (NHIS) regarding persons with cardiovascular disease. The NHIS is an annual, cross-sectional survey representative of the U.S., noninstitutionalized, civilian population. Estimated percentages of persons with heart disease reporting influenza vaccination were relatively stable during the 1996–97 through 2000–2001 influenza seasons, with the highest levels in most groups occurring in 1999–2000: 49.2% (95% confidence interval [CI], 44.1%–54.3%) among persons aged 50 to 64 years; and 22.7% (95% CI, 18.2%–27.2%) among persons aged 18 to 49 years. Influenza vaccine coverage among adults aged 18 to 64 years with cardiovascular disease is substantially below the national objective. Multiple strategies are needed to improve vaccination coverage, such as increasing the awareness of and demand for vaccination by persons with heart disease; increasing implementation by providers of practices that have been shown to increase vaccination levels; and adopting of influenza vaccination by primary care providers and specialists as a standard of care for persons diagnosed with cardiovascular disease.
PMCID: PMC387428  PMID: 15061622
Cardiovascular diseases; health services/utilization; influenza/epidemiology/prevention & control; human; influenza vaccine; knowledge, attitudes, practice; National Health Interview Survey; patient acceptance of health care; physician's practice patterns; pneumonia; population surveillance; risk factors; United States; vaccination/utilization
16.  The Impact of the 2004–2005 Influenza Vaccine Shortage in the Veterans Health Administration 
Journal of General Internal Medicine  2007;22(8):1132-1138.
The Veterans Health Administration (VHA) serves a population at high risk of influenza-related morbidity and mortality. The national public health response to the vaccine shortage of the 2004–2005 season resulted in prioritization of recipients and redistribution of available supply.
To characterize the impact of the 2004–2005 influenza vaccine shortage on vaccination among users of VHA facilities.
Analysis using data from the cross-sectional VHA Survey of Healthcare Experiences of Patients.
Outpatients seen in VHA clinics during the months September 2004–March 2005.
Sociodemographics, vaccination prevalence, setting of vaccination, and reasons cited for not getting vaccinated.
Influenza vaccination prevalence among VHA outpatients aged 50–64 was 56% and for those aged ≥65 was 86%. Compared to the 2 previous seasons, this estimate was lower for patients age 50–64 but similar for patients ≥65. After adjustment for patient characteristics, unvaccinated patients aged 50–64 were 8.3 (95% CI 6.0, 11.4) times as likely to cite that they were told they were not eligible for vaccination because of the national shortage compared to patients ≥65. Regional VHA variation in vaccination receipt and shortage-related reasons for nonvaccination was small.
The national influenza vaccine shortage of 2004–2005 primarily affected VHA users aged 50–64, consistent with the tiered prioritization guidance issued by the Centers for Disease Control and Prevention and Advisory Committee on Immunization Practices. Despite the shortage, vaccination prevalence among VHA users ≥65 remained high.
PMCID: PMC2305749  PMID: 17546477
influenza vaccine; veteran; vaccine shortage
17.  Improving uptake of influenza vaccination among older people: a randomised controlled trial. 
BACKGROUND: The uptake of influenza vaccination among older people is suboptimal. Contact with a doctor or nurse is associated with older people deciding to accept influenza vaccination. AIM: To compare different forms of approach in improving uptake of influenza vaccination among patients aged 75 years and over in primary care. DESIGN OF STUDY: Randomised controlled trial. SETTING: One large rural general practice serving the town and surrounding area of Melton Mowbray, Leicestershire. METHOD: All 2,052 patients aged 75 years and over, registered with the practice and not living in nursing/residential homes or sheltered accommodation, were included in the study. One-third of patients were randomised to receive an offer of influenza vaccination as part of an over-75 health check administered by a practice nurse in the patient's home, and two-thirds of patients were randomised to receive a personal letter of invitation to attend an influenza vaccination clinic held at the surgery. The main outcome measure was uptake of influenza vaccination. RESULTS: Six hundred and eighty patients were randomised to the health check arm of the trial and 1,372 were randomised to receive a personal letter. Of those randomised to the health check arm, 468 received the health check from the nurse. Overall, the difference in influenza vaccination uptake was 6.4% (95% confidence interval [CI] = 2.2% to 10.4%) with 67.9% (n = 932) of those who were sent a personal letter actually receiving the vaccine, compared with 74.3% (n = 505) of those offered a combined health check and influenza vaccination (P = 0.003). CONCLUSION: Combining home-based over- 75 health checks with influenza vaccination can improve uptake among older patients. However this intervention is likely to be costly and its effect on influenza vaccination rates is modest. The difference in uptake is greater among those who do not routinely comeforwardfor vaccination and a more viable option may be to target these patients.
PMCID: PMC1314411  PMID: 12236274
18.  Routine immunization of adults in Canada: Review of the epidemiology of vaccine-preventable diseases and current recommendations for primary prevention 
Vaccination is one of the greatest achievements in public health of the 20th century. However, the success of vaccine uptake and adherence to immunization guidelines seen in pediatric populations has not been observed among adult Canadians. As a result of the disparity in susceptibility to vaccine-preventable disease, there has been an increasing shift of vaccine-preventable childhood diseases into adult populations. Accordingly, morbidity and mortality due to vaccine-preventable illnesses now occur disproportionately in adults. All Canadians, irrespective of age, should have immunity to measles, mumps, rubella, tetanus, diphtheria, pertussis and varicella. All adult Canadians with significant medical comorbidities or those older than 65 years of age should receive the pneumococcal polysaccharide vaccine and yearly trivalent inactivate influenza vaccines. The present review summarizes the burden of illness of these vaccine-preventable diseases in the Canadian adult population and reviews the current immunization recommendations. Vaccination of all Canadians to these common agents remains a vital tool to decrease individual morbidity and mortality and reduce the overall burden of preventable disease in Canada.
PMCID: PMC2770305  PMID: 20808459
Influenza; Measles; Pertussis; Pneumococcus; Tetanus; Varicella
19.  Barriers to pandemic influenza vaccination and uptake of seasonal influenza vaccine in the post-pandemic season in Germany 
BMC Public Health  2012;12:938.
In Germany, annual vaccination against seasonal influenza is recommended for certain target groups (e.g. persons aged ≥60 years, chronically ill persons, healthcare workers (HCW)). In season 2009/10, vaccination against pandemic influenza A(H1N1)pdm09, which was controversially discussed in the public, was recommended for the whole population. The objectives of this study were to assess vaccination coverage for seasonal (seasons 2008/09-2010/11) and pandemic influenza (season 2009/10), to identify predictors of and barriers to pandemic vaccine uptake and whether the controversial discussions on pandemic vaccination has had a negative impact on seasonal influenza vaccine uptake in Germany.
We analysed data from the ‘German Health Update’ (GEDA10) telephone survey (n=22,050) and a smaller GEDA10-follow-up survey (n=2,493), which were both representative of the general population aged ≥18 years living in Germany.
Overall only 8.8% of the adult population in Germany received a vaccination against pandemic influenza. High socioeconomic status, having received a seasonal influenza shot in the previous season, and belonging to a target group for seasonal influenza vaccination were independently associated with the uptake of pandemic vaccines. The main reasons for not receiving a pandemic vaccination were ‘fear of side effects’ and the opinion that ‘vaccination was not necessary’. Seasonal influenza vaccine uptake in the pre-pandemic season 2008/09 was 52.8% among persons aged ≥60 years; 30.5% among HCW, and 43.3% among chronically ill persons. A decrease in vaccination coverage was observed across all target groups in the first post-pandemic season 2010/11 (50.6%, 25.8%, and 41.0% vaccination coverage, respectively).
Seasonal influenza vaccination coverage in Germany remains in all target groups below 75%, which is a declared goal of the European Union. Our results suggest that controversial public discussions about safety and the benefits of pandemic influenza vaccination may have contributed to both a very low uptake of pandemic vaccines and a decreased uptake of seasonal influenza vaccines in the first post-pandemic season. In the upcoming years, the uptake of seasonal influenza vaccines should be carefully monitored in all target groups to identify if this trend continues and to guide public health authorities in developing more effective vaccination and communication strategies for seasonal influenza vaccination.
PMCID: PMC3527143  PMID: 23113995
Vaccination; Influenza; Coverage; Pandemic; Germany
20.  Influenza Vaccination Among Adults 65 Years or Older: A 2009–2010 Community Health Survey in the Honam Region of Korea 
The present study examined the rates and related factors for influenza vaccination among the elderly Korean population during the 2008/09 influenza seasons. We obtained data for 6,391 adults aged 65 years or older from Community Health Surveys conducted in 2009 and 2010 in 13 communities in the Honam region of Korea. A multiple logistic regression analysis was used to identify the factors associated with self-reported influenza vaccinations. In this elderly population, 81.7% reported to having received an influenza vaccination in the past year. The main contributing factors were older age, lower economic status, lower educational level, married, non-smoking, regular alcohol consumption, regular walking exercise, receiving a health check-up during the past two years, not stressed, and having comorbid conditions. The influenza vaccination coverage rate among elderly Koreans was relatively high, but improvements in vaccination rates are required.
PMCID: PMC3228566  PMID: 22163202
aged; influenza; vaccination; risk factors
21.  Influenza and pneumococcal vaccine uptake among nursing home residents in Nottingham, England: a postal questionnaire survey 
BMC Geriatrics  2008;8:11.
Previous studies have shown influenza vaccine uptake in UK nursing home residents to be low. Very little information exists regarding the uptake of pneumococcal vaccine in this population. The formulation of policies relating to the vaccination of residents has been proposed as a simple step that may help improve vaccine uptake in care homes.
A postal questionnaire was sent to matrons of all care homes with nursing within the Greater Nottingham area in January 2006. Non respondents were followed up with up to 3 phone calls.
30% (16/53) of respondents reported having a policy addressing influenza vaccination and 15% (8/53) had a policy addressing pneumococcal vaccination. Seasonal influenza vaccine coverage in care homes with a vaccination policy was 87% compared with 84% in care homes without a policy (p = 0.47). The uptake of pneumococcal vaccination was found to be low, particularly in care homes with no vaccination policy. Coverage was 60% and 32% in care homes with and without a vaccination policy respectively (p = 0.06). This result was found to be statistically significant on multivariate analysis (p = 0.03, R = 0.46)
The uptake of influenza vaccine among care home residents in the Nottingham region is relatively high, although pneumococcal vaccine uptake is low. This study shows that there is an association between pneumococcal vaccine uptake and the existence of a vaccination policy in care homes, and highlights that few care homes have vaccination policies in place.
PMCID: PMC2413222  PMID: 18485209
22.  Correlates of prolonged television viewing time in older Japanese men and women 
BMC Public Health  2013;13:213.
In addition to insufficient moderate-to-vigorous physical activity (MVPA), prolonged sitting time is also a health risk for older adults. An understanding of population subgroups who have prolonged television viewing (TV) time, a predominant sedentary behavior, can aid in the development of relevant health promotion initiatives; however, few such studies have focused on older adults, the most sedentary segment of the population as a whole. The aim of this study is to examine the socio-demographic attributes associated with TV time among community-dwelling Japanese older men and women.
A population-based, cross-sectional mail survey was used to collect data on TV time, MVPA, and socio-demographic characteristics. The survey was conducted from February through March 2010. Participants were 2700 community-dwelling older adults (aged 65–74 years, 50% men) who were randomly selected from the registry of residential addresses of three cities in Japan. Data from 1665 participants (mean age: 69.5 years, 52% men) who completed all variables for the present study were analyzed. Multivariate logistic regression analyses were used to calculate the odds ratios (ORs) of prolonged TV time (>2 hours/day) for each socio-demographic attribute, stratified by gender.
Of the 1665 participants, 810 (48.6%) watched TV for more than 2 hours/day. The median television viewing time (25th, 75th percentile) was 2.00 (1.07, 3.50) hours/day. Prolonged TV time was associated with not in full-time employment, lower educational attainment, weight status, living in regional areas and low MVPA for the whole sample. For men, prolonged TV time was associated with lower educational attainment; (OR = 1.53, 95% CI: 1.12-2.07), underweight (OR = 1.63, 95% CI: 1.02-2.60), overweight (OR = 1.57, 95% CI: 1.11-2.21), and low MVPA (OR = 1.43, 95% CI: 1.02-2.02). For women, living in regional areas (OR = 2.02, 95% CI: 1.33-3.08), living alone (OR = 1.61, 95% CI: 1.03-2.49), not driving (OR = 1.79, 95% CI 1.21-2.65), overweight (OR = 1.50, 95% CI: 1.00-2.24), and low MVPA (OR = 1.51. 95% CI: 1.05-2.17) were associated with prolonged TV time.
These findings identify particular socio-demographic and behavioral characteristics related to TV time among Japanese older adults. It should be noted that correlates of prolonged TV time differed by gender. Women in living situations with limited transportation options tended to spend prolonged time watching TV. Health promotion initiatives for older adults, particularly for older women, may be more effective if they take these attributes into account.
PMCID: PMC3605336  PMID: 23496962
Sedentary behavior; Socio-demographic attributes; Population-based study; Cross-sectional study
23.  Factors Influencing H1N1 Vaccination Among Primary Health Care Workers: A Cross-Sectional Study 
Primary health care workers (PHCW) are the front-liners in any infectious disease outbreaks. The recent outbreak of H1N1 influenza demonstrated that uptake of H1N1 vaccination remained low amongst PCHW despite its proven effectiveness. This trend is worrying as PHCW are the first point of contact in any emerging outbreak of future influenza epidemic. To investigate factors influencing willingness of H1N1 vaccination amongst PHCW.
A cross-sectional survey using self-reported questionnaire assessing perception and practice towards H1N1 Influenza A vaccination. A score of 34/50 was used as a cut-off score that divide good and poor perception. Logistic regression analysis used to explore the association between acceptance to be vaccinated and chosen variables.
The mean age was 33.91 (SD: 8.20) with mean year of service of 9.23 (SD: 8.0). Acceptance of H1N1 vaccination was 86.3%. A total of 85.9% perceived the vaccination can prevent serious disease. Willingness to be vaccinated influenced by perception at risk of having illness (OR: 10.182, CI: 1.64-63.23, P 0.013) and need for vaccination (OR: 11.35, CI: 4.67-27.56, P < 0.0001).
PCHW were generally willing to be vaccinated should H1N1 Influenza epidemic emerges in the future. However, acceptance of vaccination was influenced by factors of benefit to prevent illness and reduction of spread of the illness. Fear of side-effects remained a barrier toward acceptance which should be taken into account in planning of preparation for future wave of outbreak.
PMCID: PMC3733034  PMID: 23930184
Influenza A (H1N1) vaccination; practice; primary health care workers
24.  Influenza and tetanus immunization. Are adults up-to-date in rural Alberta? 
Canadian Family Physician  1997;43:50-55.
PURPOSE: To discover what proportion of adults residing within the boundaries of a rural health district were up-to-date with influenza and tetanus vaccinations. METHODS: A directory-seeded, random digit dial telephone survey of health knowledge, attitudes, and practices was conducted in summer 1993. Eligible subjects were aged 16 or older, lived within health district boundaries, and spoke English. RESULTS: Just over half (57.5%) of people aged 65 and older had received influenza vaccine in the previous 12 months, and 55.4% of people 16 years and older had received tetanus vaccine in the last 10 years (93% of people aged 16 to 24 were covered, but only 20.5% of people aged 65 or older). Most (89.8%) of those 65 and older knew that influenza vaccine was recommended for people their age. Only 59% of respondents knew that influenza vaccine was recommended for people with chronic health conditions, regardless of age. CONCLUSION: Among adults, coverage with influenza and tetanus vaccines varies with age, but is generally unsatisfactory. Rates in this rural area of Alberta were similar to Canadian rates for tetanus vaccine coverage but higher for influenza vaccine coverage.
PMCID: PMC2255162  PMID: 9626423
25.  Awareness and acceptability of human papillomavirus vaccine: an application of the instrumental variables bivariate probit model 
BMC Public Health  2012;12:31.
Although lower uptake rates of the human papillomavirus (HPV) vaccine among socioeconomically disadvantaged populations have been documented, less is known about the relationships between awareness and acceptability, and other factors affecting HPV vaccine uptake.
The current study aimed to estimate the potential effectiveness of increased HPV vaccine awareness on the acceptability of HPV vaccination in a nationally representative sample of women, using a methodology that controlled for potential non-random selection.
This study used a population-based sample from the 2007 Health Information National Trends Survey, a cross-sectional study of the US population aged 18 years or older, and focused on the subsample of 742 women who have any female children under the age of 18 years in the household. An instrumental variables bivariate probit model was used to jointly estimate HPV vaccine awareness and acceptability.
The proportion of HPV vaccine acceptability among the previously aware and non-aware groups was 58% and 47%, respectively. Results from the instrumental variables bivariate probit model showed that the estimated marginal effect of awareness on acceptability was 46 percentage points, an effect that was even greater than observed.
Among populations who are not currently aware of the HPV vaccine, the potential impact of raising awareness on acceptability of HPV vaccination is substantial. This finding provides additional support to strengthening public health programs that increase awareness and policy efforts that address barriers to HPV vaccination.
PMCID: PMC3292959  PMID: 22240031
Preventive medicine; Sexually transmitted infections; Gynecology

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