DRIVERS AND BARRIERS OF SEASONAL INFLUENZA VACCINATION IN THE EUROPEAN UNION AND EUROPEAN ECONOMIC AREA (EU/EEA): A SYSTEMATIC REVIEW

Abstract

Background
Vaccination against seasonal influenza reduces disease burden in target groups such as older people, individuals with chronic diseases, pregnant women, small children and health care workers (HCWs). Vaccination policies and programmes vary and coverage is below the 75% EU Council Recommendation target in all EU/EEA member states except the Netherlands. A systematic review of the evidence about drivers and barriers to seasonal influenza vaccination uptake was conducted to inform national and EU level policies.

Methods
We searched Medline, EMBASE and the Cochrane Library for papers published in English between 2008 and 2012. Two authors screened articles, appraised quality and extracted data. A percentage of all articles were independently assessed with level of agreement evaluated and differences resolved by discussion.

Results
29 of 4,981 articles met the inclusion criteria; among these were systematic reviews, randomized controlled trials (RCTs), cohort, case-control and cross sectional studies.

For older people, standard reminder postcards or letters and personalized postcards or phone calls work. For individuals with chronic medical conditions, effectiveness varies by condition. Reminder systems do increase influenza vaccination rates in asthmatic children from 10% to a maximum of 21%.

Among HCWs, there is strong evidence that multi-component campaigns - inclusion of education/promotion and improved access to vaccines - increase vaccination (up to 68.5%) in non-hospital settings. Mandatory vaccination policies achieve the highest uptake with vaccination rates over 95% consistently reported.

Evidence on drivers and barriers of seasonal influenza vaccination for healthy children and pregnant women is limited to qualitative studies and natural experiments.

Conclusions
There is a shortage of peer-reviewed literature on the drivers and barriers to seasonal influenza vaccination. This systematic review identified strategies to improve uptake of seasonal influenza vaccination in target groups, particularly older people and HCWs. Successful interventions should be implemented to reduce the burden of influenza and related morbidity and mortality in the EU/EEA. Future interventions should be clearly defined and rigorously evaluated.
EU/EEA states should prioritise evidence-based plans to improve influenza vaccination uptake.

Full text

Review of the scientific literature on drivers and barriers
of seasonal influenza vaccination coverage in the
EU/EEA.
Luciana Brondi1, Martin Higgins2, Sheila Fisken1, Dermot Gorman2,
Duncan McCormick3, Alison McCallum1 and the European Centre for
Disease Control (ECDC)
1University of Edinburgh, Scotland
2NHS Lothian, Scotland
3Scottish Government Chief Medical Officer’s Group

Why this project?
Vaccination is an effective way to limit morbidity and mortality
attributable to flu.
Older age groups (65 years and older, usually)
Individuals >6 months old with chronic medical conditions:
Pregnant women (not all member states)
Children below 2 or below 5 years (not all member states)
Healthcare workers
2009 Council of the European Union Recommendation:
Increase seasonal influenza vaccination coverage:
> 75% among older people & other groups (if possible)
Targets to be reached by the 2014-2015 season

VENICE project and trends in influenza vaccination in
Europe (2010-11 season) show variation
All countries vaccinate older ages, chronic medical conditions
(with variation), 19 for pregnant women, 19 neurological
disease, 9 morbid obesity, 7 for children
Coverage varies widely between countries:
Older people: Netherlands (80.6%)/Estonia (1.1%)
Residents at long-term care stay facilities (2 reports):
Portugal (82.9%)/Slovakia (85.4%)
HCW (7 report): Romania (63.9%)/Norway (14%)
Clinical risks : Netherlands (68.9%)/Portugal (29.4%)
Pregnant: England (36.6%)/Romania (3.6%)

Key questions
What are the drivers and barriers for increased seasonal flu
vaccination coverage in the various risk/target groups in the
EU/EEA?
How can the current low rates of healthcare workers
influenza vaccination coverage be improved?
Can we identify examples of good practice from the
literature that increase vaccination uptake in all groups?
What are the current gaps in research on the drivers and
barriers to increase seasonal flu vaccination coverage?

Evidence selection
Figure 1.Evidence selection for drivers and barriers of seasonal influenza
vaccination coverage in the EU/ EEA: a systematic review.
Interventions:
Systematic Reviews
& RCTs
Other facilitators &
barriers: other study
designs
Evidence statements:
strength (quantity,
type, quality) of
evidence & applicability
to EEA/ EU context
Time & resource limited
ability to explore other
languages

Summary findings
Few robust intervention studies.
Lots of observation comparing one year with another.
There is most evidence relating to older people and
healthcare workers.
But there is a paucity of evidence about effective
interventions – individual or multi-component
Many interventions increase uptake to less than 60%
among target population
Children and pregnant women are relatively new target
groups for flu vaccination in English speaking countries–
lack of evidence is neither a surprise nor an excuse

Summary findings
Healthcare workers:
Mostly ‘black box’, multi-component interventions; some
success increasing vaccination rates but never above 90%
Mandatory policy is effective: rates above 90% -- but there
are ethical and legal issues; opt out could be an option
The impact of role models (flu champions) could be further
explored in research in the EU
Older people:
Successful interventions: personalized reminders, home
visits, facilitators

Summary findings
Children:
Parents are key mediators of child vaccination
Live vaccine promising option for children
Pregnant women:
Multi-staff intervention required for pregnant women?
Chronic conditions:
Evidence scattered, mainly from the US, might not apply
to people with chronic conditions who already receive
wraparound care.

Overview
The experience of countries (i.e. UK, The Netherlands)
with high uptakes, can provide insight for guidance
Funding agencies should make rigorous evaluation of
flu vaccination programmes a priority
Improving influenza vaccination rates is primarily a
social intervention. Lessons from health improvement
about engaging with easily ignored groups offer
potential for increasing vaccination uptake
Data is vital -- health systems need to be able to
identify eligible patients to vaccinate, to monitor, to
evaluate effectiveness of vaccine and interventions to
increase uptake.

The black box of flu vaccination
Stone et al’s (2002) systematic review of approaches to
increase patient vaccination suggested that organisational
change and mainstreaming are key along with a theory of
behaviour change. Most flu campaigns adopt components of
Stone’s recommendations – but rates remain low
Do we really understand the issue? How does the black box
work? What counts as evidence?
–Case studies and qualitative work to understand the
variables and, critically, the processes and pathways
Dynamic between communicable and non-communicable
disease is important.
–Emphasis on NCDs should not be at expense of CD
–Learning from health improvement/social determinants of
health about access & barriers is essential

http://ecdc.europa.eu/en/publications/Publications/seasonal-
influenza-vaccination-drivers-barriers.pdf

http://www.health-in-mind.org.uk/assets/files/Report%207%20Working%20with%20Gypsy
%20Travellers%20final.pdf

Literature Search
Medline/PubMed
EMBASE
Cochrane Library (DARE, NHS EED and HTA) databases
Period: 2008-2012 (November)
Search strategy
English language only

Screening and Data abstraction/appraisal
Title; title and abstract; full text;
2 reviewers, screening form developed and tested and level of
agreement measured in 10% of papers assessed independently
Criteria (use of screening form):
Participants: risk groups and HCW
Outcomes: increase, decrease or no change
Drivers and barriers: interventions and others
Study design: Systematic Reviews, RCTs, observational studies,
qualitative;
GATE adapted checklist proposed by NICE and adapted version of
SIGN checklist for systematic reviews
Rates for study quality (-, +, ++)
Evidence tables: characteristics of studies, risk of bias, summary of
results/effects
Applicability to the EU/EEA context