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1.  Determinants of adults' intention to vaccinate against pandemic swine flu 
BMC Public Health  2011;11:15.
Vaccination is one of the cornerstones of controlling an influenza pandemic. To optimise vaccination rates in the general population, ways of identifying determinants that influence decisions to have or not to have a vaccination need to be understood. Therefore, this study aimed to predict intention to have a swine influenza vaccination in an adult population in the UK. An extension of the Theory of Planned Behaviour provided the theoretical framework for the study.
Three hundred and sixty two adults from the UK, who were not in vaccination priority groups, completed either an online (n = 306) or pen and paper (n = 56) questionnaire. Data were collected from 30th October 2009, just after swine flu vaccination became available in the UK, and concluded on 31st December 2009. The main outcome of interest was future swine flu vaccination intentions.
The extended Theory of Planned Behaviour predicted 60% of adults' intention to have a swine flu vaccination with attitude, subjective norm, perceived control, anticipating feelings of regret (the impact of missing a vaccination opportunity), intention to have a seasonal vaccine this year, one perceived barrier: "I cannot be bothered to get a swine flu vaccination" and two perceived benefits: "vaccination decreases my chance of getting swine flu or its complications" and "if I get vaccinated for swine flu, I will decrease the frequency of having to consult my doctor," being significant predictors of intention. Black British were less likely to intend to have a vaccination compared to Asian or White respondents.
Theoretical frameworks which identify determinants that influence decisions to have a pandemic influenza vaccination are useful. The implications of this research are discussed with a view to maximising any future pandemic influenza vaccination uptake using theoretically-driven applications.
PMCID: PMC3024930  PMID: 21211000
2.  Knowledge, attitudes and perceptions of health professionals in relation to A/H1N1 influenza and its vaccine 
Emerging Health Threats Journal  2012;5:10.3402/ehtj.v5i0.7266.
To determine the intention of health professionals, doctors and nurses, concerning whether or not to be vaccinated against A/H1N1 influenza virus, and their perception of the severity of this pandemic compared with seasonal flu.
Material and Methods
A cross-sectional study was carried out based on an questionnaire e-mailed to health professionals in public healthcare centres in Vitoria between 6 and 16 November 2009; the percentage of respondents who wanted to be vaccinated and who perceived the pandemic flu to carry a high risk of death were calculated.
A total of 115 people completed the questionnaire of whom 61.7% (n=71) were doctors and 38.3% (n=44) were nurses. Of these, 33.3% (n=23) of doctors and 13.6% (n=6) of nurses intended to be vaccinated (p=0.019). Even among those who considered themselves to be at a high risk, 70.6% (n=48) of doctors and 31.7% (n=13) of nurses participating in the study (p=0.001) planned to have the vaccination.
Most health professionals, and in particular nurses, had no intention to be vaccinated against A/H1N1 influenza virus at the beginning of the vaccination campaign.
PMCID: PMC3257874  PMID: 22461846
A/H1N1 influenza virus; vaccination; health professionals; doctors; nurses
3.  Workplace Vaccination and Other Factors Impacting Influenza Vaccination Decision among Employees in Israel 
The study examined the factors affecting the decision to be vaccinated against influenza among employees in Israel. The research, conducted in 2007/2008, included 616 employees aged 18−65 at various workplaces in Israel, among them companies that offered their employees influenza vaccination. The research questionnaire included socio-demographic characteristics, and the Health Belief Model principles. The results show that the significant factors affecting vaccination compliance include a vaccination program at workplaces, vaccinations in the past, higher levels of vaccine’s perceived benefits, and lower levels of barriers to getting the vaccine. We conclude that vaccine compliance is larger at companies with workplace vaccination programs providing easier accessibility to vaccination.
PMCID: PMC2872324  PMID: 20617008
influenza vaccination; health belief model; employees
4.  Influenza A H1N1 2009 (Swine Flu) and Pregnancy 
The Influenza A H1N1 pandemic (A H1N1) occurred between June 2009 and August 2010. Although the pandemic is now over, the virus has emerged as the predominant strain in the current seasonal influenza phase in the northern hemisphere. The A H1N1 influenza is a novel strain of the influenza A virus and is widely known as swine flu. The virus contains a mixture of genetic material from human, pig and bird flu virus. It is a new variety of flu which people have not had much immunity to. Much has been learnt from the Pandemic of 2009/2010 but the messages about vaccination and treatment seem to be taken slowly by the clinical profession. Most people affected by the virus, including pregnant women, suffer a mild viral illness, and make a full recovery. The median duration of illness is around seven days. This influenza typically affects the younger age group i.e. from the ages of 5–65 years. Current experience shows that the age group experiencing increased morbidity and mortality rates are in those under 65 years of age. Pregnant women, because of their altered immunity and physiological adaptations, are at higher risk of developing pulmonary complications, especially in the second and third trimesters. In the United Kingdom, twelve maternal deaths were reported to be associated with the H1N1 virus during the pandemic and clear avoidable factors were identified (Modder, Review of Maternal Deaths in the UK related to A H1N1 2009 influenza (CMACE)., 2010). The pregnancy outcomes were also poor for women who were affected by the virus with a fivefold increase in the perinatal mortality rate and threefold increase in the preterm delivery rate (Yates et al. Health Technol Assess 14(34):109–182, 2010). There continues to be a low uptake of the flu vaccine and commencement of antiviral treatment for pregnant women.
PMCID: PMC3295877  PMID: 22851818
A H1N1 influenza; Swine flu; Pregnancy; Antiviral drugs; Vaccines
5.  H1N1 Influenza A infection 
Hippokratia  2009;13(3):135-138.
The 2009 flu outbreak in humans, known as "swine influenza" or H1N1 influenza A, refers to influenza A due to a new H1N1 strain called swine-origin influenza virus A (S-OIV). The new swine flu virus is actually a genetic mixture of two strains, both found in swine, of unknown origin. S-OIV can be transmitted from human to human and causes the normal symptoms of influenza. Prevention of swine influenza spread among humans includes use of standard infection control measures against influenza and constitutes the main scope of World Health Organization. For the treatment of S-OIV influenza oseltamivir and zanamivir are effective in most cases. Prophylaxis against this new flu strain is expected through a new vaccine, which is not available yet. Worldwide extension of S-OIV is a strong signal that a pandemic is imminent and indicates that response actions against S-OIV must be aggressive.
PMCID: PMC2765289  PMID: 19918299
swine influenza; H1N1 influenza virus A; infection control; oseltamivir; zanamivir
6.  Public views of the uk media and government reaction to the 2009 swine flu pandemic 
BMC Public Health  2010;10:697.
The first cases of influenza A/H1N1 (swine flu) were confirmed in the UK on 27th April 2009, after a novel virus first identified in Mexico rapidly evolved into a pandemic. The swine flu outbreak was the first pandemic in more than 40 years and for many, their first encounter with a major influenza outbreak. This study examines public understandings of the pandemic, exploring how people deciphered the threat and perceived they could control the risks.
Purposive sampling was used to recruit seventy three people (61 women and 12 men) to take part in 14 focus group discussions around the time of the second wave in swine flu cases.
These discussions showed that there was little evidence of the public over-reacting, that people believed the threat of contracting swine flu was inevitable, and that they assessed their own self-efficacy for protecting against it to be low. Respondents assessed a greater risk to their health from the vaccine than from the disease. Such findings could have led to apathy about following the UK Governments recommended health protective behaviours, and a sub-optimal level of vaccine uptake. More generally, people were confused about the difference between seasonal influenza and swine flu and their vaccines.
This research suggests a gap in public understandings which could hinder attempts to communicate about novel flu viruses in the future. There was general support for the government's handling of the pandemic, although its public awareness campaign was deemed ineffectual as few people changed their current hand hygiene practices. There was less support for the media who were deemed to have over-reported the swine flu pandemic.
PMCID: PMC2998491  PMID: 21078169
7.  Utilizing the Health Belief Model to predicting female middle school students' behavioral intention of weight reduction by weight status 
Nutrition Research and Practice  2011;5(4):337-348.
Weight reduction behavior is common among adolescent girls. The present study examined the status of weight reduction behavior and factors affecting the behavioral intention of weight reduction using the Health Belief Model (HBM) for female middle school students by weight category. Survey data was collected from three girl's middle schools in Gyeongju, Korea. A total of 299 female middle school students participated in this study. The questionnaire had questions about general characteristics, weight reduction behavior, and variables of HBM (perceived threat, perceived benefits, perceived barriers, cues to action, self-efficacy in dietary life and exercise, and behavioral intention of weight reduction). Descriptive statistics, Chi-square tests, ANOVA, and multiple regression analysis were applied to analyze the variables. A higher percentage of students in the overweight group attempted weight reduction than those in the underweight and the normal weight groups (P < 0.001). Among students who had attempted weight reduction, 73% tried diet therapy, while 78% tried exercise. Students in the normal and overweight groups showed significantly higher threat (P < 0.01) and cues to action (P < 0.001) than those in the underweight group. As for perceived benefits, barriers, and self-efficacy in dietary life and exercise, there were no significant differences among weight groups. Students in the overweight group showed the strongest intention of weight reduction and there were significant differences among the three weight groups (P < 0.001). Perceive threat (P < 0.01), cues to action (P < 0.001), and perceived self-efficacy (P < 0.01) were significantly associated to behavioral intention of weight reduction for all respondents. For the underweight group, perceived threat (P < 0.05) and perceived self-efficacy (P < 0.01) were the significant variables. For the overweight group, cue to action was the significant variable (P < 0.05).
PMCID: PMC3180685  PMID: 21994529
Health Belief Model; weight reduction; female middle school students
8.  Reassuring and managing patients with concerns about swine flu: Qualitative interviews with callers to NHS Direct 
BMC Public Health  2010;10:451.
During the early stages of the 2009 swine flu (influenza H1N1) outbreak, the large majority of patients who contacted the health services about the illness did not have it. In the UK, the NHS Direct telephone service was used by many of these patients. We used qualitative interviews to identify the main reasons why people approached NHS Direct with concerns about swine flu and to identify aspects of their contact which were reassuring, using a framework approach.
33 patients participated in semi-structured interviews. All patients had telephoned NHS Direct between 11 and 14 May with concerns about swine flu and had been assessed as being unlikely to have the illness.
Reasons for seeking advice about swine flu included: the presence of unexpectedly severe flu-like symptoms; uncertainties about how one can catch swine flu; concern about giving it to others; pressure from friends or employers; and seeking 'peace of mind.' Most participants found speaking to NHS Direct reassuring or useful. Helpful aspects included: having swine flu ruled out; receiving an alternative explanation for symptoms; clarification on how swine flu is transmitted; and the perceived credibility of NHS Direct. No-one reported anything that had increased their anxiety and only one participant subsequently sought additional advice about swine flu from elsewhere.
Future major incidents involving other forms of chemical, biological or radiological hazards may also cause large numbers of unexposed people to seek health advice. Our data suggest that providing telephone triage and information is helpful in such instances, particularly where advice can be given via a trusted, pre-existing service.
PMCID: PMC2919480  PMID: 20678192
9.  Two Types of Antibodies Are Induced by Vaccination with A/California/2009pdm Virus: Binding near the Sialic Acid-Binding Pocket and Neutralizing Both H1N1 and H5N1 Viruses 
PLoS ONE  2014;9(2):e87305.
Many people have a history of catching the flu several times during childhood but no additional flu in adulthood, even without vaccination. We analyzed the total repertoire of antibodies (Abs) against influenza A group 1 viruses induced in such a flu-resistant person after vaccination with 2009 H1N1 pandemic influenza virus. They were classified into two types, with no exceptions. The first type, the products of B cells newly induced through vaccination, binds near the sialic acid-binding pocket. The second type, the products of long-lived memory B cells established before vaccination, utilizes the 1-69 VH gene, binds to the stem of HA, and neutralizes both H1N1 and H5N1 viruses with few exceptions. These observations indicate that the sialic acid-binding pocket and its surrounding region are immunogenically very potent and majority of the B cells whose growth is newly induced by vaccination produce Abs that recognize these regions. However, they play a role in protection against influenza virus infection for a short period since variant viruses that have acquired resistance to these Abs become dominant. On the other hand, although the stem of HA is immunogenically not potent, the second type of B cells eventually becomes dominant. Thus, a selection system should function in forming the repertoire of long-lived memory B cells and the stability of the epitope would greatly affect the fate of the memory cells. Acquisition of the ability to produce Abs that bind to the stable epitope could be a major factor of flu resistance.
PMCID: PMC3914828  PMID: 24505283
10.  Influenza H1N1 (swine flu) vaccination: a safety surveillance feasibility study using self-reporting of serious adverse events and pregnancy outcomes 
During the global H1N1 influenza A (swine flu) pandemic 2009–2010, swine flu vaccines were expeditiously licensed and a mass vaccination programme for high risk groups, including pregnant women, was introduced in the UK. This pilot active safety surveillance study was performed to establish the feasibility of rapidly monitoring the new swine flu vaccines in large patient numbers receiving or offered the vaccination under normal conditions of use within a short time frame.
A cohort design with safety data capture through modern technologies was carried out in Scotland, UK during the winter swine flu vaccination programme 2009–2010 in individuals receiving or offered the swine flu vaccination. The main outcome measures were self-reported serious adverse events (SAEs) and pregnancy outcomes.
The cohort comprised 4066 people; 3754 vaccinated and 312 offered the vaccination but not vaccinated. There were 939 self-reported events (838 different events), 53 judged to fit SAE criteria by the investigators, with nine judged as possibly, probably or definitely vaccine related. None of the seven deaths (six in vaccinees) were judged as vaccine related. One hundred and twenty-eight women reported 130 pregnancies during the study with 117 pregnant at study start. There were reports of four miscarriages in three women and six possible congenital abnormalities in live births.
Overall, no significant safety issues were identified. The methodology and use of modern technologies to collect safety data from large numbers of patients was successful and could be used again in similar safety studies.
PMCID: PMC3403208  PMID: 22082196
H1N1 vaccination; post marketing; safety surveillance
11.  Influenza H1N1 (swine flu) vaccination: a safety surveillance feasibility study using self-reporting of serious adverse events and pregnancy outcomes 
During the global H1N1 influenza A (swine flu) pandemic 2009–2010, swine flu vaccines were expeditiously licensed and a mass vaccination programme for high risk groups, including pregnant women, was introduced in the UK. This pilot active safety surveillance study was performed to establish the feasibility of rapidly monitoring the new swine flu vaccines in large patient numbers receiving or offered the vaccination under normal conditions of use within a short time frame.
A cohort design with safety data capture through modern technologies was carried out in Scotland, UK during the winter swine flu vaccination programme 2009–2010 in individuals receiving or offered the swine flu vaccination. The main outcome measures were self-reported serious adverse events (SAEs) and pregnancy outcomes.
The cohort comprised 4066 people; 3754 vaccinated and 312 offered the vaccination but not vaccinated. There were 939 self-reported events (838 different events), 53 judged to fit SAE criteria by the investigators, with nine judged as possibly, probably or definitely vaccine related. None of the seven deaths (six in vaccinees) were judged as vaccine related. One hundred and twenty-eight women reported 130 pregnancies during the study with 117 pregnant at study start. There were reports of four miscarriages in three women and six possible congenital abnormalities in live births.
Overall, no significant safety issues were identified. The methodology and use of modern technologies to collect safety data from large numbers of patients was successful and could be used again in similar safety studies.
PMCID: PMC3403208  PMID: 22082196
H1N1 vaccination; post marketing; safety surveillance
12.  Trends in influenza vaccination coverage rates in Germany over five seasons from 2001 to 2006 
To assess influenza vaccination coverage from 2001 to 2006 in Germany, to understand drivers and barriers to vaccination and to identify vaccination intentions for season 2006/07.
9,990 telephone-based household surveys from age 14 were conducted between 2001 and 2006. Essentially, the same questionnaire was used in all seasons.
The influenza vaccination coverage rate reached 32.5% in 2005/06. In the elderly (≥60 years), the vaccination rate reached 58.9% in 2005/06. In those aged 65 years and older, it was 63.4%. Perceiving influenza as a serious illness was the most frequent reason for getting vaccinated. Thirteen percent of those vaccinated in 2005/06 indicated the threat of avian flu as a reason. The main reason for not getting vaccinated was thinking about it without putting it into practice. The major encouraging factor to vaccination was a recommendation by the family doctor. 49.6% of the respondents intend to get vaccinated against influenza in season 2006/07.
Increasing vaccination rates were observed from 2001 to 2006 in Germany. The threat of avian influenza and the extended reimbursement programs may have contributed to the recent increase.
PMCID: PMC2233630  PMID: 18070354
13.  College Students’ Perceptions of H1N1 Flu Risk and Attitudes toward Vaccination 
Vaccine  2011;29(44):7599-7601.
College students are highly susceptible to the H1N1 virus, yet previous studies suggest that college students perceive themselves at low risk for the flu. We surveyed 514 undergraduates to assess their perceptions of H1N1 flu risk and opinions about flu vaccines. A third of respondents stated that they were not at risk of getting the H1N1 flu because they were young. Responses indicated a distrust of the safety and effectiveness of influenza vaccinations; only 15.8% of participants planned on receiving H1N1 vaccination. Top reasons for refusing the H1N1 vaccine included questioning vaccine safety and effectiveness, and concerns about potential serious and/or benign side effects. Top reasons for H1N1 vaccination acceptance included receiving a doctor recommendation for the vaccine, having previously gotten a seasonal vaccine, and being at high-risk for influenza. Our findings suggest that college students are inaccurate in assessing their risk level and are unlikely to seek vaccinations.
PMCID: PMC3190084  PMID: 21827812
H1N1 influenza; influenza vaccination; college students; flu risk perception
14.  Determinants of Non-Vaccination against Pandemic 2009 H1N1 Influenza in Pregnant Women: A Prospective Cohort Study 
PLoS ONE  2011;6(6):e20900.
In October 2009, the French government organized a national-wide, free of charge vaccination campaign against pandemic H1N1 influenza virus, especially targeting pregnant women, a high risk group for severe illness. The study objective was to evaluate pandemic flu vaccine uptake and factors associated with non-vaccination in a population of pregnant women.
Methodology/Principal Findings
In a prospective cohort conducted in 3 maternity hospitals in Paris, 882 pregnant women were randomly included between October 12, 2009 and February 3, 2010, with the aim to study characteristics of pandemic influenza during pregnancy. At inclusion, socio-demographic, medical, obstetrical factors and those associated with a higher risk of flu exposition and disease-spreading were systematically collected. Pandemic flu vaccine uptake was checked until delivery. 555 (62.9%) women did not get vaccinated. Determinants associated with non-vaccination in a multivariate logistic regression were: geographic origin (Sub-Saharan African origin, adjusted Odd Ratio aOR = 5.4[2.3–12.7], North African origin, aOR = 2.5[1.3–4.7] and Asian origin, aOR = 2.1[1.7–2.6] compared to French and European origin) and socio-professional categories (farmers, craftsmen and tradesmen, aOR = 2.3[2.0–2.6], intermediate professionals, aOR = 1.3[1.0–1.6], employees and manual workers, aOR = 2.5[1.4–4.4] compared to managers and intellectual professionals). The probability of not receiving pandemic flu vaccine was lower among women vaccinated against seasonal flu in the previous 5 years (aOR = 0.6[0.4–0.8]) and among those who stopped smoking before or early during pregnancy (aOR = 0.6[0.4–0.8]). Number of children less than 18 years old living at home, work in contact with children or in healthcare area, or professional contact with the public, were not associated with a higher vaccine uptake.
In this cohort of pregnant women, vaccine coverage against pandemic 2009 A/H1N1 flu was low, particularly in immigrant women and those having a low socio-economic status. To improve its effectiveness, future vaccination campaign for pregnant women should be more specifically tailored for these populations.
PMCID: PMC3114856  PMID: 21695074
15.  Factors Affecting Acceptance and Intention to Receive Pandemic Influenza A H1N1 Vaccine among Primary School Children: A Cross-Sectional Study in Birmingham, UK 
UK pandemic influenza strategy focused on vaccination of high risk groups, although evidence shows that school-age children have the highest infection rates. Vaccination of children might be an additional strategy. We undertook a cross-sectional study amongst 149 parents of primary school children aged 4–7 years in Birmingham, UK to quantify intention to accept pandemic influenza vaccine and identify factors affecting uptake. Ninety-one (61.1%, 95% CI 52.8, 68.9) had or would accept vaccine for their child. The most common reasons for declining vaccine were concerns about safety (58.6% reported this), side effects (55.2%), or believing their child had already had swine flu (12.1%). Parents of nonwhite ethnicity (OR 2.4 (1.1, 5.0)) and with asthmatic children (OR 6.6 (1.4, 32.1)) were significantly more likely to accept pandemic vaccine, as were those whose children had ever received seasonal vaccine and those who believed swine flu to be a serious threat (OR 4.2 (1.9, 9.1)). Parents would be more likely to accept vaccination if they received a letter of invite, if the government strongly encouraged them, if it were administered at school, and if it were more thoroughly tested. Accurate media portrayal of safety of the vaccine during future pandemics will be essential.
PMCID: PMC3485484  PMID: 23150815
16.  Clinical Profile of Patients Admitted with Swine-Origin Influenza A (H1N1) Virus Infection: An Experience from A Tertiary Care Hospital 
Background: Pandemic influenza A (H1N1) 2009 has posed a serious public health challenge world-wide. H1N1 critical illness mostly affects young patients and is often fatal.
Objective: Primary objective was to study clinical profile of the patients admitted with confirmed H1N1 swine flu infection. Secondary objective was to observe the risk factors associated with complications like need of mechanical ventilation and or death among H1N1 infected patients.
Material and Methods: A prospective observational study was conducted in a tertiary care teaching hospital from June 2009, to December, 2011. H1N1 infection was confirmed by reverse transcriptase PCR. Statistical analysis was done by SPSS, version 11. Binary logistic regression was used to find out independent risk factors for morbidity.
Results: Total 495 patients were tested for H1N1 infection. Among them, 115 (23%) were positive and 88(76%) required admission. Median age of cohort was 29 years and 87% of the patients were below 54 years of age. Most common presenting symptoms were fever (98%), followed by cough (86%) and sore throat (54%). Out of 88 patients, 14 (16%) required mechanical ventilation and 6(6.8%) died. Lymphopaenia (Lymphocytes <10%) and presence of patchy infiltrates on chest X-ray (CXR) the time of presentation were independent risk factors associated with need of mechanical ventilation or death in H1N1 infected patients by multivariate analysis.
Conclusion: Present study showed that H1N1 swine flu mainly affected people who were < 54 years of age. Majority of patients improved with antiviral treatment. Lymphopaenia and CXR which showed bilateral pneumonia at time of presentation were found to be independent risk factors associated with requirement of mechanical ventilation and/or death in H1N1 infection. Pregnant females with flu constituted 33% of total mortality. High priority should be given to such patients. Further community based studies are required to analyze the actual impact of H1N1 infection in the community.
PMCID: PMC3843408  PMID: 24298482
H1N1; swine flu; lymphopaenia; bilateral pneumonia
17.  Difference in immune response in vaccinated and unvaccinated Swedish individuals after the 2009 influenza pandemic 
BMC Infectious Diseases  2014;14:319.
Previous exposures to flu and subsequent immune responses may impact on 2009/2010 pandemic flu vaccine responses and clinical symptoms upon infection with the 2009 pandemic H1N1 influenza strain. Qualitative and quantitative differences in humoral and cellular immune responses associated with the flu vaccination in 2009/2010 (pandemic H1N1 vaccine) and natural infection have not yet been described in detail. We designed a longitudinal study to examine influenza- (flu-) specific immune responses and the association between pre-existing flu responses, symptoms of influenza-like illness (ILI), impact of pandemic flu infection, and pandemic flu vaccination in a cohort of 2,040 individuals in Sweden in 2009–2010.
Cellular flu-specific immune responses were assessed by whole-blood antigen stimulation assay, and humoral responses by a single radial hemolysis test.
Previous seasonal flu vaccination was associated with significantly lower flu-specific IFN-γ responses (using a whole-blood assay) at study entry. Pandemic flu vaccination induced long-lived T-cell responses (measured by IFN-γ production) to influenza A strains, influenza B strains, and the matrix (M1) antigen. In contrast, individuals with pandemic flu infection (PCR positive) exhibited increased flu-specific T-cell responses shortly after onset of ILI symptoms but the immune response decreased after the flu season (spring 2010). We identified non-pandemic-flu vaccinated participants without ILI symptoms who showed an IFN-γ production profile similar to pandemic-flu infected participants, suggesting exposure without experiencing clinical symptoms.
Strong and long-lived flu-M1 specific immune responses, defined by IFN-γ production, in individuals after vaccination suggest that M1-responses may contribute to protective cellular immune responses. Silent flu infections appeared to be frequent in 2009/2010. The pandemic flu vaccine induced qualitatively and quantitatively different humoral and cellular immune responses as compared to infection with the 2009 H1N1 pandemic H1N1 influenza strain.
PMCID: PMC4067073  PMID: 24916787
T-cells; H1N1; Immune protection; Flu antigens; Vaccine take; Epidemiology; Influenza; Pandemic
18.  Have the public's expectations for antibiotics for acute uncomplicated respiratory tract infections changed since the H1N1 influenza pandemic? A qualitative interview and quantitative questionnaire study 
BMJ Open  2012;2(2):e000674.
To investigate the effect of the H1N1 influenza pandemic on the public's expectations for a general practice consultation and antibiotic for acute respiratory illness.
Mixed methods.
Qualitative interviews: 17 participants with acute respiratory tract infection (RTI) visiting English pharmacies. Face-to-face survey: about 1700 adults aged 15 years and older were recruited from households in England in January 2008, 2009 and 2011.
The qualitative data indicated that the general public had either forgotten about the ‘swine flu’ (H1N1 influenza) pandemic or it did not concern them as it had not affected them directly or affected their management of their current RTI illness. Between 2009 and 2011, we found that there was little or no change in people's expectations for antibiotics for runny nose, colds, sore throat or cough, but people's expectations for antibiotics for flu increased (26%–32%, p=0.004). Of the 1000 respondents in 2011 with an RTI in the previous 6 months, 13% reported that they took care of themselves without contacting their general practitioners and would not have done so before the pandemic, 9% reported that they had contacted their doctor's surgery and would not have done so before the pandemic and 0.6% stated that they had asked for antibiotics and would not have done so before the pandemic. In 2011, of 123 respondents with a young child (0–4 years) having an RTI in the previous 6 months, 7.4% requested antibiotics and would not have done so before the pandemic. Unprompted, 20% of respondents thought Tamiflu© (oseltamivir) was a vaccine.
Expectations of the general public for a consultation or antibiotics with an RTI are similar now to before the H1N1 influenza pandemic; therefore, public antibiotic campaign messages and general practice advice to patients can remain unchanged. Parents with young children and those with personal experience of the H1N1 influenza are more likely to consult and will need more reassurance. The public need more education about Tamiflu©.
Article summary
Article focus
The H1N1 (2009) pandemic has ‘medicalised’ acute respiratory illness presenting with flu-like symptoms, including cough, cold, sore throat and fever.
The general public may now have a greater expectation that they should seek a consultation with a health professional and have a greater expectation for antibiotics when they next have an acute respiratory illness presenting with flu-like symptoms, including cough, cold, sore throat and fever.
To determine if expectations for a consultation or an anti-infective have changed as a result of the publics' experiences of the recent (2009) H1N1 influenza pandemic and to explore the publics' understanding of anti-infectives.
Key messages
The H1N1 influenza pandemic has not changed the general public's expectations for a general practitioner's consultation or antibiotics when they have a runny nose, cough, cold or sore throat but may have increased people's expectations for antibiotics for influenza.
Most have either forgotten about the influenza outbreak or it did not concern them as it had not affected them directly.
The smaller subsets of the public with young children and those who have had suspected or confirmed H1N1 influenza themselves are now more likely to consult and request an antibiotic for an RTI and, therefore, these groups will need more guidance and reassurance.
A fifth of the public believe that Tamiflu© (oseltamivir) is a vaccine, implying that enhanced information sharing is needed in this area.
Strengths and limitations of this study
This was a large survey of the general population, repeating some of the questions asked before the 2009 H1N1 flu epidemic, using the same sampling methods.
The qualitative interviews had recruitment problems with many potential interviewees not being at home when telephoned. However, the purpose of qualitative interviews was mainly to enrich our data, and they did help explain our quantitative findings.
The questionnaire survey asked to recall their most recent RTI in the previous 6 months and what actions they took on that occasion. This will be subject to some recall bias.
PMCID: PMC3323811  PMID: 22457479
19.  A Study of the Swine Flu (H1N1) Epidemic Among Health Care Providers of a Medical College Hospital of Delhi 
Influenza viruses cause annual epidemics and occasional pandemics that have claimed the lives of millions. Understanding the role of specific perceptions in motivating people to engage in precautionary behavior may help health communicators to improve their messages about outbreaks of new infectious disease generally and swine flu specifically.
To study the knowledge and practices of health care providers regarding swine flu and to study the attitudes and practices of health care providers toward the prevention of the swine flu epidemic.
Materials and Methods:
The present study was a cross-sectional (descriptive) study and was conducted in the month of September, 2009, among doctors and nurses. A maximum of 40% of the total health care providers of GTB Hospital were covered because of feasibility and logistics, and, therefore, the sample size was 334.
Around 75% of the health care providers were aware about the symptoms of swine flu. Mostly, all study subjects were aware that it is transmitted through droplet infection. Correct knowledge of the incubation period of swine flu was known to 80% of the doctors and 69% of the nurses. Knowledge about high-risk groups (contacts, travelers, health care providers) was observed among 88% of the doctors and 78.8% of the nurses. Practice of wearing mask during duty hours was observed among 82.6% of doctors and 85% of nurses, whereas of the total study population, only 40% were correctly using mask during duty hours.
Significant gaps observed between knowledge and actual practice of the Health Care Provider regarding swine flu need to be filled by appropriate training. Data indicate that the health care providers are very intellectual, but they do not themselves practice what they preach.
PMCID: PMC3214442  PMID: 22090671
Swineflu; H1N1; pandemic; health care provider; influenza
20.  Neutrophils to lymphocyte ratio as a screening tool for swine influenza 
Background & objectives:
During an outbreak of influenza like illness throat swab culture and virus isolation are done to identify causal virus, and it may cause a significant delay in diagnosis and isolation. There is a need to determine a sensitive laboratory parameter which could play a major role in identifying H1N1 infection among patients presenting with influenza like symptoms. We undertook this study to determine a laboratory parameter to identify swine influenza infection amoung patients presenting with influenza like symptoms while awaiting throat swab culture and virus isolation reports.
This retrospective study was conducted on patients presenting to A.P TB and Chest Hospital, Hyderabad, with swine influenza symptoms during September-October 2009. They were divided into swine flu positive (SW+) and swine flu negative (SW-) groups, based on their throat swab culture reports and laboratory data. Neutrophils to lymphocyte (N/L) ratio was calculated for every patient and also mean N/L ratio for two groups. Mean WBC count was also noted for both groups.
There were 55 patients in each group. The WBC count in SW+ group varied from 3000 to 10600 cells/mm3 (mean 5714), while in SW- group it varied from 4500 to 14300 cells/mm3 (10252). The N/L ratio was less than two for 92.7 per cent of patients in SW+ group and for 3.63 per cent patients in SW- group. N/L ratio < 2 as an indicator for swine flu had a sensitivity of 92.7 per cent and specificity of 96.36 per cent. It has a positive predictive value of 96.22 per cent and a negative predictive value of 92.8 per cent.
Interpretation & conclusions:
N/L < 2 along with a decrease in WBC count can be used as a screening tool in patients presenting with influenza like symptoms, while awaiting throat swab culture reports for confirmation.
PMCID: PMC3193722  PMID: 21985824
H1N1 influenza; lymphocytes; neutrophils; screening tool; swine influenza
21.  Initial psychological responses to Influenza A, H1N1 ("Swine flu") 
The outbreak of the pandemic flu, Influenza A H1N1 (Swine Flu) in early 2009, provided a major challenge to health services around the world. Previous pandemics have led to stockpiling of goods, the victimisation of particular population groups, and the cancellation of travel and the boycotting of particular foods (e.g. pork). We examined initial behavioural and attitudinal responses towards Influenza A, H1N1 ("Swine flu") in the six days following the WHO pandemic alert level 5, and regional differences in these responses.
328 respondents completed a cross-sectional Internet or paper-based questionnaire study in Malaysia (N = 180) or Europe (N = 148). Measures assessed changes in transport usage, purchase of preparatory goods for a pandemic, perceived risk groups, indicators of anxiety, assessed estimated mortality rates for seasonal flu, effectiveness of seasonal flu vaccination, and changes in pork consumption
26% of the respondents were 'very concerned' about being a flu victim (42% Malaysians, 5% Europeans, p < .001). 36% reported reduced public transport use (48% Malaysia, 22% Europe, p < .001), 39% flight cancellations (56% Malaysia, 17% Europe, p < .001). 8% had purchased preparatory materials (e.g. face masks: 8% Malaysia, 7% Europe), 41% Malaysia (15% Europe) intended to do so (p < .001). 63% of Europeans, 19% of Malaysians had discussed the pandemic with friends (p < .001). Groups seen as at 'high risk' of infection included the immune compromised (mentioned by 87% respondents), pig farmers (70%), elderly (57%), prostitutes/highly sexually active (53%), and the homeless (53%). In data collected only in Europe, 64% greatly underestimated the mortality rates of seasonal flu, 26% believed seasonal flu vaccination gave protection against swine flu. 7% had reduced/stopped eating pork. 3% had purchased anti-viral drugs for use at home, while 32% intended to do so if the pandemic worsened.
Initial responses to Influenza A show large regional differences in anxiety, with Malaysians more anxious and more likely to reduce travel and to buy masks and food. Discussions with family and friends may reinforce existing anxiety levels. Particular groups (homosexuals, prostitutes, the homeless) are perceived as at greater risk, potentially leading to increased prejudice during a pandemic. Europeans underestimated mortality of seasonal flu, and require more information about the protection given by seasonal flu inoculation.
PMCID: PMC2765446  PMID: 19807908
22.  Influenza Vaccination Uptake among the Working Age Population of Japan: Results from a National Cross-Sectional Survey 
PLoS ONE  2013;8(3):e59272.
Influenza vaccination rates among Japanese people of working age (20–69 years) is currently suboptimal, and the reasons for this have not been clearly elucidated. This study examined factors associated with vaccination intention among the working age population in Japan during September 2011, one-month prior to influenza vaccination becoming available.
Methodology/Principal Findings
A web-based survey of intention to be vaccinated against influenza in the coming season was undertaken among 3,129 Japanese aged 20 to 69 years. Multinomial logistic regression analysis was used to explore the associations between vaccination intent and other variables. Influenza vaccination intent was associated with having been vaccinated in the previous year (Odds Ratio (OR): 3.81; 95% Confidence Interval (CI): 3.75–3.86), the number of children per household (one compared with zero; OR: 1.37; 95%CI: 1.11–1.65), and household income ($50,000 to <$100,000 compared with $0 to <$50,000; OR: 1.30; 95%CI: 1.07–1.54). Smoking was inversely associated with influenza vaccine uptake (current smokers compared with non-smokers; OR: 0.79; 95%CI: 0.61–0.98). A history of either the survey respondent or a household member having being medically diagnosed with influenza in the previous year was not statistically associated with future influenza vaccination intent.
Overall, this suggests that intention to be vaccinated among working age Japanese is associated with a past history of influenza vaccination, having children, and the household's income. As such, consideration of these factors should now form the cornerstone of strategies to encourage increased uptake of vaccination against influenza in future years.
PMCID: PMC3595249  PMID: 23555010
23.  Lymphadenitis as a Rare Side Effect of H1N1 Vaccine in a Child 
Case Reports in Medicine  2010;2010:459543.
We present a 5-year-old boy who had the complaint of swelling and pain on the right vaccine shot and right axillary areas. The right axillary area was diagnosed as reactive lymphadenitis, which we believe is a rare local side effect of the swine flu vaccine. The key message to take away from this case is that the patient had lymphadenitis as a local side effect of the swine flu vaccine. Lymphadenitis should be reported as a possible local side effect of the swine flu vaccine.
PMCID: PMC3014838  PMID: 21209734
24.  Childhood swine flu vaccination uptake in a Welsh general practice: a prospective study 
The British Journal of General Practice  2011;61(588):e392-e396.
Immunisation of infants is effective and benefits the health of the children immunised as well as the community where uptake is high. Any social inequality in uptake will worsen any social inequalities that already exist.
To investigate the demographic characteristics of families attending for swine flu vaccination.
Design and setting
A prospective study in a semi-rural general practice in South Wales.
Data were collected by questionnaire, and logistic regression models were used to test for associations between potential risk factors (including family demographic characteristics and the child's previous vaccination history) and swine flu vaccination uptake.
No evidence was found of any significant associations between potential risk factors and the outcome.
This suggests that social inequality did not affect vaccination uptake in this sample.
PMCID: PMC3123501  PMID: 21722446
case control studies; child; health promotion; humans; immunisation; infant; influenza; primary care; Wales
25.  Effects of Mass Media Coverage on Timing and Annual Receipt of Influenza Vaccination among Medicare Elderly 
Health Services Research  2010;45(5 Pt 1):1287-1309.
To measure the association between mass media coverage on flu-related topics and influenza vaccination, regarding timing and annual vaccination rates, among the nationally representative community-dwelling elderly.
Data Source
Years 1999, 2000, and 2001 Medicare Current Beneficiary Survey.
Study Design
Cross-sectional survival analyses during each of three influenza vaccination seasons between September 1999 and December 2001. The outcome variable was daily vaccine receipt. We measured daily media coverage by counting the number of television program transcripts and newspaper/wire service articles, including keywords of influenza/flu and vaccine/shot shortage/delay. All models' covariates included three types of media, vaccine supply, and regional/individual factors.
Principal Findings
Influenza-related reports in all three media sources had a positive association with earlier vaccination timing and annual vaccination rate. Four television networks' reports had most consistent positive effects in all models, for example, shifting the mean vaccination timing earlier by 1.8–4.1 days (p<.001) or increasing the annual vaccination rate by 2.3–7.9 percentage points (p<.001). These effects tended to be greater when reported in a headline rather than in text only and if including additional keywords, for example, vaccine shortage/delay.
Timing and annual receipt of influenza vaccination appear to be influenced by media coverage, particularly by headlines and specific reports on shortage/delay.
PMCID: PMC2939276  PMID: 20579128
Vaccination; influenza; vaccination timing; annual vaccination rate; mass media coverage

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