Low vaccination coverage for seasonal influenza and pneumococcal disease among adults at-risk and health care workers in Ireland, 2013: The key role of GPs in recommending vaccination
Introduction
Influenza is a highly infectious disease which has significant morbidity and mortality. Invasive streptococcus pneumoniae can cause serious disease or death, particularly for at-risk groups [1], [2]. Both diseases are potentially vaccine preventable and there is good international evidence of which groups benefit from vaccination with either vaccine [1], [2]. Most high and middle-income countries have vaccination recommendations together with funding mechanisms to encourage vaccination, particularly for influenza [3]. International studies have identified a wide range of factors associated with vaccine acceptance, including social and cultural beliefs, access to services, and public policies.
Despite strong international and national vaccination recommendations uptake among risk groups there has been little progress made in Ireland in recent years [3]. The European Commission (EC) recommends that all EU countries monitor seasonal influenza vaccination coverage in high risk groups. The World Health Organization (WHO) and the European Centre for Disease Prevention and Control (ECDC) have defined risk groups for influenza as persons at higher risk of having an adverse outcome (e.g. severe disease or death) from infection, including individuals aged ≥65 years, those with specified medical conditions (including pregnancy), and health care workers (HCWs) [4], [5]. Invasive pneumococcal disease is a particular risk for the very young, the elderly and those with chronic medical conditions [6].
In Ireland, the National Immunisation Advisory Committee (NIAC) makes vaccine recommendations for the population. Risk groups identified are similar to those identified internationally [2], [6], [7]. The Health Services Executive of Ireland (HSE) supports the influenza and pneumococcal vaccination programme for those in at-risk groups by providing free vaccines. Vaccine administration fees may apply for individuals ineligible for free access to primary care services (General Medical Service [GMS] medical card or GP visit [GPV] card) [8]. Eligibility for free primary care services is usually income dependent. HCWs are entitled to free vaccine administration (occupational health services). The HSE-National Immunization Office (HSE-NIO) procures and distributes influenza vaccine to health care facilities (hospitals, long-term care facilities, GP practices and community pharmacies). Pneumococcal vaccines are provided to GP sites. HSE-NIO promotes these vaccines using a variety of media (radio or television, leaflets, posters).
In Ireland, there is no comprehensive information system with which to estimate uptake of influenza or pneumococcal vaccines among at-risk adults. In an effort to fill this gap the Health Protection Surveillance Centre (HPSC) uses administrative data (payment claims from GP or pharmacies) to estimate uptake among elderly entitled to free vaccination. For HCWs, surveys of health care facilities have been done since 2011 [9]. Previous work done by HSE-NIO in 2011 identified potential barriers to influenza vaccination (including low risk perception, concerns about vaccine side effects and costs of vaccine administration) [10].
Between August and October 2013, we undertook a survey from a sample of the Irish adult population to: estimate the proportion of community-based adults who had risk conditions, or were HCWs, for whom influenza or pneumococcal vaccination was recommended; estimate vaccination coverage among those groups; and identify factors associated with seasonal influenza vaccination status during the influenza season 2012–2013.
Section snippets
Study design and population
We conducted a national telephone survey among adults aged 18 years and over, residing in Ireland (non-institutionalised), using computer assisted telephone interviews (CATI). This survey followed similar methodology to previous national telephone surveys in 2006 [11] and in 2010 [12].
Sampling methods
We used quota sampling methods.
Quota sampling reflected the demographics based on age, sex and region of residence of the Irish population.
We estimated the sample size Open Epi, version 3 (//www.openepi.com/v37/SampleSize/SSPropor.htm
At-risk population in Ireland
Of 18,238 valid telephone contacts made, we interviewed 1770 (10%) persons. Compared with 2011 census data, those in the 25–34 years age group were under-represented, while those in 50–64 year age group were over-represented; those in the HSE Eastern region (HSE-E), which includes the greater Dublin metropolitan area were over-represented (Table 1).
Among all respondents, 35% (610/1770) [95%CI: 32%–37%] were at-risk for influenza due to age or medical conditions; 16% (285/1770) [95%CI: 14%–18%]
Discussion
The survey provided information on vaccination uptake for those at-risk population groups for whom there is little available data. For influenza, overall vaccine uptake among at-risk populations was below the EU/WHO recommended target of 75%. For pneumococcal vaccination, vaccination uptake, as found in this study, was poor despite long standing recommendations in Ireland.
Conclusions
Influenza vaccination was low in all at-risk groups (age, medical conditions and HCWs) and below the EU target. Despite improvements in HCW influenza vaccine uptake, awareness of the importance of vaccination among this group remained poor. Pneumococcal vaccination in at-risk individuals has increased over the years but remains low. The most commonly reported reason for not getting influenza vaccination was the perception of low risk. Doctors’ recommendations and access to free vaccine
Recommendations
More effort is needed to increase seasonal influenza vaccination coverage in at-risk populations, especially in those <65 years of age with underlying medical conditions and HCWs. Pneumococcal vaccine uptake needs to be increased in all at-risk age groups. At GP level, local audits could be considered to monitor uptake. Specific condition-specific and age-based strategies should be adopted in order to increase vaccine uptake [18], [22]. Implementing evidence-based programmes are needed to
Acknowledgements
The authors wish to thank all those who participated to the study and the company Milward Brown who conducted the interviews on behalf of HPSC. The study was funded by the Health Services Executive – Health Protection Surveillance Centre.
Author's contribution: Study protocol and questionnaire: JM, SC, JOD, DOF; Data analysis: CG, JM, KD, SC; Writing of article: CG, SC, JM, JOD, DOF; Reviewing of article: SC, JM, KD, JO’D, DOF.
Conflict of interest statement: None of the authors have any conflict
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