Influenza Vaccination – Increasing uptake within a general practice population
Introduction
Seasonal influenza is an acute viral infection which is responsible for annual epidemics during the
winter months. While most people infected with influenza will recover within one week without the
need for medical attention, influenza can cause serious illness and death in those considered to be at
high risk. Worldwide, an annual influenza epidemic is estimated to result in approximately 3-5 million
cases of severe illness and 250,000 to 500,000 deaths1. Aside from the traditional at risk groups of
the elderly and those with chronic disease, there is increasing awareness that other groups within the
population should be regarded as at higher than average risk of severe disease. As such, the National
Immunisation Advisory Committee added new recommendations for 2010/2011 influenza season in
Ireland. Currently, the following groups are eligible for the influenza vaccine, with an asterix marking
groups newly added for the most recent flu season2:

Persons aged 65 years or older

Residents of nursing homes or long term care facilities

Health care workers/Carers

Persons with immunosuppression due to disease or treatment

Persons of any age with chronic illness requiring regular medical follow up (includes chronic
respiratory disease, chronic heart disease, diabetes and chronic renal disease)

All pregnant or postpartum women*

Chronic liver disease*

Chronic neurological disease*

Morbid obesity (BMI > 40)*

Children with any condition that can compromise respiratory function, especially those
attending special schools/day centres*

People with close, regular contact with pigs, poultry or water fowl*
Vaccination is both a safe and effective means of preventing illness and reducing complications
secondary to influenza. Among healthy adults, vaccination prevents 70-90% of influenza specific
illness and among the elderly, vaccination reduces severe illness and complications by up to 60% and
deaths by up to 80%1.
Currently in Ireland, there is no system of estimating the uptake of influenza vaccine in at risk groups
except for persons aged 65 years and older. For the 2008/2009 flu season, vaccine uptake in the over
65 age group was 70.1%. A study in 2005/2006 estimated the number of people aged between 18
and 64 years who were eligible for vaccination and concluded that uptake of the influenza vaccine in
this age category to be 28%3. With regard to this study, 60% of non-vaccinated individuals, for whom
vaccination was indicated, perceived themselves to be at low risk of influenza. This underpins the
importance of increasing awareness of eligibility criteria. Interestingly, half of influenza-vaccinated
respondents reported that their family doctor had recommended it. This finding has been supported
by several international studies which have found that the family doctor is the most important source
of encouragement for people to be vaccinated against influenza4,5,6.
In consideration of the above information, this research project was designed around using a variety
of means to increase awareness of the eligibility criteria for influenza vaccination and determining
whether this increased vaccine uptake within our practice population. Our practice has a patient
population of approximately 10,000 patients with 5% of patients being age 70 years or older. Prior to
the 2010/2011 influenza season, administration of the vaccine in the practice would have been solely
opportunistic. The practice uses Socrates software.
Aims/Objectives
Our project aims were as follows:
1) To increase awareness of the indications for influenza vaccination, both within the patient
population and amongst health care practitioners in the practice
2) To form a register of those patients who qualified for the flu vaccine
3) To contact eligible patients who were delayed in attending for vaccination
4) To ascertain patient knowledge of indications for vaccination, attitudes to vaccination and any
potential barriers that may exist by means of a self-answered questionnaire
Our project objectives were as follows:
1) To assess if the overall uptake of the seasonal influenza vaccine had increased in 2010/2011
as compared with the same period in 2009/2010
2) To quantify what proportion of those patients deemed to be eligible for the vaccine had
received it
3) To ascertain what proportion of patients directly contacted by the practice subsequently
attended for vaccination
Methodology
A list was formed of all patients who had received the influenza vaccine during the 2009/2010 flu
season.
Increasing awareness:
At the beginning of the influenza season, vaccination was discussed at a practice meeting attended
by all health care practitioners in the surgery. An overview was given of changes in the practice
approach for the 2010/2011 flu season and current eligibility criteria, including new target groups as
per the HSE, were discussed.
A large poster was placed in the practice waiting room. This listed groups eligible for the flu vaccine,
stated that it was available in the practice and advised regarding cost (free for eligible GMS patients;
cost of vaccine and administration for eligible private patients). In addition, laminated A4 size posters
were placed in high visibility areas in all rooms used by health care practitioners.
During the peak vaccination period, flu clinics were established in the practice. On approximately two
afternoons per week, a number of the practice nurses’ appointments were designated for consecutive
flu vaccinations.
Formation of register:
A register of all patients eligible for the 2010/2011 influenza vaccine was formed. Patients who were
residents of nursing homes or long term care facilities were added to the register, as were all patients
on warfarin therapy. Most of the register was created by utilizing the reports feature on Socrates
software. Patients aged 65 years or older were identified using age as a search criteria. Pregnant
patients were identified by checking for registration on the antenatal protocol. In the absence of coded
diagnoses and in an effort to make the register as accurate as possible, patients with chronic disease
were identified by searching via prescriptions. Searches were limited to patients under 65 years with
the prescription being issued in the previous 18 months and focused on commonly used medications
in chronic respiratory disease, chronic heart disease and diabetes. (e.g. search performed for all
patients < 65 years who had received a prescription for beclomethasone in previous 18 months).
Each patient’s chart was then reviewed to confirm eligibility.
Once the register was complete, any patient who featured on it was tagged when they booked an
appointment. When the attended their appointment with the doctor/practice nurse, their name was
highlighted to indicate that they were eligible for the vaccine. Administration of the vaccine was
recorded on the register.
Letters:
Once the initial rush for vaccination started to decrease, letters were posted to all remaining patients
on the register who had yet to receive the vaccine. The letter advised them that they were eligible and
that it was recommended that they receive the vaccine. A record was kept of all patients who had
been contacted by post.
Questionnaires:
Once the letters had been sent, any patient who received the flu vaccine after that point was asked to
complete a short questionnaire. This included all patients who attended for a flu vaccine, regardless of
whether or not they had received a letter. The purpose of the questionnaire was to ascertain patient
knowledge of the flu vaccine, to establish if they had attended for vaccination secondary to receiving a
letter and to explore any patient concerns or possible barriers to receiving the vaccine.
Following the implementation of the above steps, the number of vaccines administered between
01/09/2010 and 31/01/2011 was calculated.
Results
For the 2009/2010 influenza season, a total of 380 vaccines were administered within the practice.
For the 2010/2011 influenza season, 862 vaccines were administered. With a practice population of
approximately 10,000 patients, vaccination coverage for the total population was 3.80% in 2009/2010
and increased to 8.62% in 2010/2011. The total number of patients on the register, and therefore
eligible for the flu vaccine, was 1265 and of these patients, 808 received the vaccine with a resulting
vaccination coverage within target groups of 63.87%. Of the 352 patients who received a reminder in
the form of a letter, 117 went on to have the flu vaccine. Therefore the response rate to a personal
invitation was 33.24%.
With regard to the self-answered questionnaires, 53 were completed with each questionnaire
consisting of 6 questions. When asked about there being any reason for their delayed attendance,
13.2% of patients had been unaware that the vaccine was available and 26.4% of patients had been
unaware that they were eligible. 30.2% of patients had delayed in attending due to a lack of free time.
5.7% of patients were unsure why they qualified for vaccination. 35.8% of respondents stated that by
receiving the vaccine they would avoid getting flu whereas only 5.7% stated that receiving the vaccine
would decrease the risk of contracting flu. Another 5.7% stated that it would decrease complications if
flu was contracted.
Discussion
In the two consecutive influenza seasons surveyed in this study, vaccine administration rates
increased from 380 in 2009/2010 to 862 in 2010/2011. With regard to the 1265 patients who featured
on the register, 808 received the vaccine resulting in a vaccine uptake rate of 63.87% amongst target
groups. This figure is roughly comparable to national uptake rates according to the HSE (61.7% in
2007/2008 and 70.1% in 2008/2009). However it must be noted that while national uptake rates refer
only to those aged 65 and older, our figure for vaccine uptake refers to all target groups.
In our questionnaire, just over a quarter (26.4%) of those surveyed had delayed in getting the vaccine
as they had been unaware that they were eligible. As mentioned previously, this finding is supported
by previous studies which have identified poor perception of risk amongst those for whom vaccination
is actually indicated. We can therefore conclude that increasing awareness of eligibility criteria
amongst patients has the potential to improve vaccine uptake. 30.2% of patients surveyed cited lack
of free time as a reason for delay in attending. The organisation of flu clinics may partly address this
issue. In this situation, patients could expect less waiting time and a more time efficient service.
In summary, this study has demonstrated that increasing awareness of eligibility criteria for
vaccination both within the patient population and amongst health care practitioners, along with the
formation of a register, had a positive impact on influenza vaccine uptake within our practice.
References
1
WHO, Influenza, fact sheet No 211(2008) www.who.int/mediacentre/factsheets/fs211/en/
2
Immunisation Guidelines for Ireland. 2010 Edition. National Immunisation Advisory Committee
3
Mereckiene J, O’Donnell J, Collins C. Risk groups and uptake of influenza and pneumococcal
vaccine in Ireland. Euro Suveill, 12(12), 756(2007)
4
Horby P, Williams A, Burgess M, Wang H. Prevalence and determinants of influenza vaccination in
Australians aged 40 years and over – a national survey. Australian and New Zealand Journal of
Public Health, 2005;Vol.29(1)
5
Wiese-Posselt M, Leitmeyer K, Hamouda O, Bocter N, Zollner I, Haas W, Ammon A. Influenza
vaccination coverage in adults belonging to defined target groups, Germany, 2003/2004.
Vaccine,2006;24:2560-2566
6
Szucs, T et al. Influenza vaccination coverage rates in five European countries—a population-based
cross-sectional analysis of two consecutive influenza seasons. Vaccine, Vol 23, Issue 43, 1 50555063
.