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Declination forms may boost flu vaccination rate in health-care workers

By Lisa Rapaport

NEW YORK (Reuters) — Asking health-care workers to complete forms explaining why they didn't get the flu vaccine may be a cost-effective way to improve vaccination rates, a new study finds.

"Evidence suggests that declination form programs which require health-care workers to provide a reason for declination and sign to acknowledge risk to self and patients by not getting vaccinated are effective at (improving) health-care worker influenza vaccination rates, and that these improvements are sustainable," lead author Sherri LaVela told Reuters Health by email.

LaVela, from the United States Department of Veterans Affairs (VA) in Hines, Ill.,and colleagues designed a pilot project to implement a declination-form program at two VA centres for patients with spinal cord injuries (SCI), a population at high risk of respiratory complications from influenza.

Under the program, workers were offered vaccination and, if they refused, given a form to complete explaining their reasons. Researchers also interviewed workers to understand what factors might influence implementation of a declination form program.

Implementation teams with leadership, nurses, physicians and infection preventionists told researchers that orientation sessions would be key to the success of any program, because it would let workers know what to expect.

Overall, with the program in place, health-care worker vaccination rates were higher for the current flu season than for the year before (77.4 per cent versus 53.5 per cent). Vaccination rates at the first site increased to 75 per cent for the current flu season from 53.9 per cent the previous year. At the second site, rates increased to 77.8 per cent from 53.3 per cent.

Data were collected from 69 workers from site 1 and 104 from site 2; the researchers say it's possible site 1 results weren't statistically significant because of the smaller sample. At site 1, 100 per cent of declination forms were completed in less than two months; total staff time to implement the program was 42.5 hours. At site 2, the program was implemented over a 4.5-month period and 49 per cent of forms were completed; here the staff devoted 26.5 hours.

On average, the total cost of staff time was $2,093 per site; average costs, excluding the research and implementation team time, were approximately $1,400. The only supplies required were the declination forms; printing costs for each site were estimated to be less than $5 (all figures in U.S. dollars).

More study is needed to understand how other initiatives at the VA and how declination form programs might be use to supplement other efforts, the researchers said.

And, while the pilot data suggest the program is feasible, larger studies are needed to understand and identify program components that might contribute to success and assess effectiveness on a broader scale in a wider variety of settings, the researchers wrote in their study.

"While evidence suggests that regular ongoing efforts, such as staff education, help improve HCW vaccination, they are not sustainable over time and have not moved vaccination rates near ideal vaccination rate targets," LaVela said. "Common reasons for not getting vaccinated include concerns about side effects and inconvenience."

The Healthy People 2020 goal for influenza vaccination among health-care workers is over 90 per cent, said Hillary Babcock, an infectious disease specialist at Washington University School of Medicine in St. Louis.

"Since any infected health-care worker could put patients at risk, ideally everyone who can be vaccinated (that is, without a medical contraindication) would be," Babcock, who wasn't involved in the study, told Reuters Health by email.

Previous research has shown that the most reliable way to achieve high vaccination levels is to make it mandatory or a condition of employment, excluding people with medical contraindications, she said.

As the current study shows, "while significant increases can be achieved with other interventions, it is rare for programs without a mandate to achieve sustained vaccination rates above 90 per cent," Babcock added.

Mandatory vaccination is not used throughout the VA Health Care System at this time, Dr. LaVela said.

With influenza, where the vaccine each year provides varying levels of protection against the strains actually circulating in the community, achieving high vaccination rates is particularly crucial for health-care workers, said Tom Talbot, chief hospital epidemiologist at Vanderbilt University Medical Center.

Talbot, who wasn't involved in the study, told Reuters Health that in the push for higher vaccination rates, a growing number of hospitals are instituting policies that — while stopping short of making vaccination mandatory — urge people to wear masks if they opt out of the shots.

"You can do the masks in a way that's non-stigmatizing for any people who can't get vaccinated for medical reasons," Talbot said, noting that some hospitals have employees place stickers on their identification badges with messages like, "I wear a mask because I care."

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