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Review of the scientific literature on drivers and barriers of seasonal influenza vaccination coverage in the EU/EEA (ECDC, November 4 2013, excerpts)

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  • Review of the scientific literature on drivers and barriers of seasonal influenza vaccination coverage in the EU/EEA (ECDC, November 4 2013, excerpts)

    [Source: European Centre for Disease Prevention and Control (ECDC), full PDF document: (LINK). Excerpts.]


    TECHNICAL REPORT

    Review of the scientific literature on drivers and barriers of seasonal influenza vaccination coverage in the EU/EEA


    This report was commissioned by the European Centre for Disease Prevention and Control (ECDC), coordinated by Teymur Noori and produced by Luciana Brondi, Martin Higgins, Dermot Gorman, Duncan McCormick, Alison McCallum (NHS Lothian, Edinburgh, Scotland, UK) and Sheila Fisken (Information Services, University of Edinburgh, Scotland, UK).

    Suggested citation: European Centre for Disease Prevention and Control. Review of scientific literature on drivers and barriers of seasonal influenza vaccination coverage in the EU/EEA. Stockholm: ECDC; 2013. Stockholm, November 2013

    ISBN 978-92-9193-498-0 / doi 10.2900/89599 / Catalogue number TQ-02-13-331-EN-N

    ? European Centre for Disease Prevention and Control, 2013

    Reproduction is authorised, provided the source is acknowledged


    Executive summary

    Every winter, influenza epidemics cause significant morbidity and mortality throughout Europe. High-risk groups such as older people, individuals with chronic diseases, pregnant women and small children are most affected by these epidemics. Healthcare workers (HCW) are also at high risk of influenza transmission to and from patients.

    Seasonal vaccination against flu viruses reduces the burden of disease in these groups and has been widely available in most EU/EEA countries for several years. However, uptake of seasonal influenza vaccination for target groups in most of these countries still falls short of the 75% coverage target established by the European Council of Ministers in 2009.

    We conducted a systematic review to identify significant evidence on drivers of and barriers to seasonal influenza vaccination of relevance to the EU/EEA. We focused on the high-risk groups which have been identified by ECDC as those where high coverage of seasonal flu vaccination is important.

    Evidence from published empirical research forms the core of this review. We searched the Medline/PubMed, EMBASE, Cochrane Library (DARE, NHS EED and HTA) databases. A detailed search strategy developed in consultation with an information specialist was used to search Medline and EMBASE. We covered all English language papers published between 2008 and 2012.

    Two authors selected articles of possible relevance for the review. A detailed screening form was developed and tested for this purpose. For the ?title and abstract? screen and the ?full text? screen, 10% per cent of the articles were independently assessed and the level of agreement evaluated. There was excellent agreement between both reviewers.

    A total of 4 981 articles were initially retrieved through Medline, EMBASE and Cochrane. After all the screening processes, 26 were included for data abstraction and appraisal in the final evidence tables. Data appraisal was conducted by two authors using standard checklists and disagreements were discussed and resolved. Studies included were then rated to indicate their quality following the process outlined in the NICE Public Health Guidance Methods Manual [1]. To create the evidence tables we used systematic reviews and randomised controlled trials (RCTs) for the evaluation of interventions to increase uptake of flu seasonal vaccine. To identify facilitating factors other than interventions, we used evidence from studies with designs such as case control, cohort or crosssectional surveys, and mainly from studies highly relevant to the European context.

    For the elderly population and healthcare workers, there is published evidence on specific types of interventions to increase the uptake of seasonal flu vaccination. For population of patients with chronic conditions, the evidence is scattered as there are not enough high quality studies in the different groups of chronically ill people and therefore transferability of conclusions between groups and in patients with multiple morbidity, requires further testing. For pregnant women and children, the evidence we found was scarce and quite low in quality and permitted fewer conclusions.

    We present the main results of our review by targeted group.


    Elderly people

    In elderly people, there is insufficient evidence for some interventions but personalised postcards or phone calls are considered effective. Home visits, and having facilitators, may be effective. Reminders to physicians alone are not effective and good quality evidence from one RCT in Japan found positive effects in the elderly population when community pharmacists personally advocated for flu vaccination.

    Observational studies suggest that individuals who are older than 85 or married, who use medical services more frequently or who suffer from a chronic disease are more likely to get vaccinated. These studies also suggest that having a case manager as part of an interdisciplinary team in a healthcare practice, and lowering the age limit for vaccination might be effective in increasing vaccination rates. Barriers to vaccination include social disadvantage, smoking, and lack of social support.


    Individuals with chronic medical conditions

    The conclusions for this subpopulation depend to a certain extent on which kind of chronic condition they suffer from. In addition, most of the interventions were conducted in the USA and some assessment of effectiveness in different healthcare systems is required. Interventions such as reminder/recall systems seem to increase influenza vaccination in asthmatic children, although adding educational messages with reminders might not increase uptake in patients with asthma. While previous studies with chronically ill children and other populations have shown the effectiveness of electronic health reminders/alerts in improving uptake of services, the USA study selected showed only modest and non-significant effect in immunisation for influenza among asthmatic children.

    Other drivers and barriers explored by observational studies in this subpopulation suggest that misperceptions about the vaccine might be a barrier to receiving vaccination. Low grade evidence from the UK shows a modest, significant coverage increase (8%) in high-risk patients under 65 when a lead staff member plans the flu campaign, and when a written performance report is produced during the vaccination campaign and results are shared with those involved in the vaccination efforts.


    Healthcare workers

    There is plenty of evidence on interventions to improve vaccine uptake in this group. One systematic review identified five types of intervention:
    • education or promotion
    • improved access to vaccination
    • legislation or regulation
    • measurement or feedback
    • role models.

    In non-hospital settings, campaigns with more components, specifically education/promotion and improved access to vaccines, had significant positive effects in vaccine uptake, more than doubling the rates in the intervention group compared to the control (risk ratio 2.26, 95% CI, 1.96?2.39), and reaching high coverage (68.5%) in the intervention group. In hospital settings, education/promotion and improved access to vaccination were the most common interventions but never raised vaccination rates above 90%. Other RCTs published since the systematic review are broadly in line with review findings in that they show little evidence that interventions such as education or promotion improved access to vaccination, measurement or feedback, or that role models are on their own effective measures to reach 90% vaccination among HCWs.
    Evidence from two observational studies from the USA suggests mandatory vaccine policies are more successful in improving rates of vaccination above 95% than relying on enabling approaches.


    Pregnant women

    There was no good quality evidence on interventions in this group. As for other drivers and barriers explored in observational studies, very low grade evidence from a cross-sectional study suggests that standing ordersi, role models, and HCW education might improve rates of coverage. Electronic reminders and education of providers might be useful. Inconsistent advice from healthcare providers may also pose a barrier to vaccine uptake in this population.


    Children

    The evidence for interventions targeting this group is scarce and weak. We found no systematic reviews or RCTs investigating interventions.

    There is low grade evidence from the USA. Cross-sectional studies focused on parents? attitudes and views.

    Common reasons why parents choose to have children vaccinated include:
    • prevention of influenza
    • physicians? recommendation
    • reduced influenza symptoms.

    Two studies from the USA and one from the UK provide some indicators for future research, although these surveys all contain notable respondent bias. Potential reasons why parents may choose not to have children vaccinated include:
    • low perception of risk of catching the disease
    • concern about safety and efficacy of vaccines
    • flu vaccine containing thiomersal.


    Adults in general

    We also present some relevant evidence on the adult population in general since not all studies focused specifically on our target groups. Low grade evidence from a cluster RCT (C-RCT) in the USA shows that electronic reminders might help improving flu vaccination rates in adults if they can access the internet and use it regularly. As for drivers and barriers explored in observational studies, low grade evidence from a survey carried out in 11 European countries suggest that countries with high per capita income have significantly higher rates of coverage in adults.

    Awareness that influenza is a serious illness, advice from a family doctor and the wish not to transmit influenza to family members and friends seems to facilitate uptake. Adults who did not think themselves likely to catch influenza or who had never considered vaccination before were less likely to be vaccinated. In addition, having to pay for vaccines is also a barrier, especially in the poorer countries.


    List of evidence statements

    Elderly people

    Evidence statement 1

    Different types of interventions in elderly people have been analysed by a high quality systematic review [2]. There was marked heterogeneity among the interventions studied and therefore many results could not be pooled. There is insufficient evidence for most of the interventions, however:
    • There is ample, although low quality, evidence that reminders work. Normal reminder postcards or letters (10 RCTs) and personalised postcards or phone calls (11 RCTs) are considered effective with entire 95% CI >1.
    • Home visits may be effective.
    • Facilitators within the clinics may be effective (3 of 4 RCTs 95% CI>1)
    • Reminders to physicians alone (only 1 out of 4 RCTs had positive effects) are not effective.

    There is good quality evidence from one C-RCT in Japan showing an increased rate of vaccination among elderly people when community pharmacists personally advocated for flu vaccination, with a difference of 8.7% in uptake (95% CI = 2.2-15.2%) [3].


    Evidence statement 2

    There is moderate evidence from one case control study involving 11 European countries suggesting that having a case manager in an interdisciplinary team might be a facilitator for higher uptake of flu vaccine in elderly people [4]. The same finding is repeated in a recent cross-sectional survey in 795 UK General Practitioner clinics [5].

    Low grade to moderate evidence from a large Italian study and a combined Ireland and Northern Ireland study suggests that being 85 or older increases the likelihood of getting the vaccine [6]. Suffering from severe chronic disease is also a strong determinant according to the Italian survey. The Italian survey also suggests that good social support significantly increases the odds of influenza vaccine use [7]. In the Ireland and Northern Ireland study, being married and greater usage of hospital and community services also increase vaccine uptake. Low grade to moderate evidence from a large Spanish study suggests that lowering the age limit might increase vaccination coverage in all groups [8].

    Moderate evidence from an Italian national survey shows that social disadvantage and being a smoker might determine low uptake of flu vaccine [9].


    Chronic conditions

    Evidence statement 3

    Low grade evidence from Esposito [10] indicates that reminder/recall systems seem to increase influenza vaccination in asthmatic children (rates increased from at least 10% to a maximum of 21% in all groups).

    Receiving a reminder from a paediatrician from the clinic and getting the vaccine in the same clinic increased uptake rates from 40 to 61.1% with RR=1.26 (1.01?1.58).

    There is moderate evidence from the USA that an added educational message with reminders might not increase uptake in patients with asthma [11].

    Although previous studies with chronically ill children have shown the effectiveness of electronic health reminders alerts in improving vaccine uptake, moderate evidence from studies from the USA show only a modest improvement [12] with a small non-significant (3.4%) increase in uptake (95%CI 1.4% to 9.1%). These results might not be directly transferable to the European context.


    Evidence statement 4

    Evidence from the USA shows that misperceptions about the vaccine might be a barrier to vaccination in this population. Perception that vaccination can actually cause the flu (adults: 48%; children 39%), and concerns about side-effects might be barriers to vaccination [11].

    A large, one season only, UK General Practice cross-sectional survey suggests a significant coverage increase of 8% in high risk patients under 65 when a lead member is planning the flu campaign and when a written performance report is produced (very low grade)[ 5].


    Healthcare workers

    Evidence statement 5

    The systematic review identified five types of intervention: education or promotion; improved access to vaccine; legislation or regulation; measurement or feedback; and role models. There is mixed evidence about the success of these interventions. The main findings are as follows:
    • In non-hospital settings, campaigns with more components, specifically education/promotion and improved access to vaccination, had higher impact with risk ratios > 1. In one, the coverage was highest when each worker had a personal interview with a member of the study team, with an average risk ratio of being vaccinated in the intervention group of 2.16 (1.96?2.43). Two other 2 RCTs found an even higher positive effect when adding role models to education and improved access, with average risk ratios of 7.06 (5.67-
      8.78) and 8.05 (6.30-10.30). However, the vaccine uptake in the intervention group was below 40%.
    • In hospital settings, education/promotion and improved access to vaccination were the most common interventions but never raised vaccination rates above 90%
    • Small studies which rely on mandatory compliance indicate vaccination rates can be increased above 90% [13].

    The other intervention RCTs published since the systematic review [14 15] are broadly in line with review findings as they show little evidence that interventions such as education or promotion, improved access to vaccination, measurement or feedback, or role models, are on their own effective measures to reach 90% vaccination among HCWs.


    Evidence statement 6

    Evidence from two observational studies suggests mandatory vaccine policies are more successful in improving rates of vaccination above 95% [16 17]. There are however ethical and legal obstacles associated with mandatory programmes.


    Evidence statement 7: Pregnant women

    We identified no high quality RCTs or systematic reviews that investigated interventions for increasing uptake of flu vaccination among pregnant women. Most studies captured by our search were cross-sectional. Very low grade evidence from one cross-sectional study suggests that standing orders, role models, and HCW education might improve rates of coverage [18]. Very low grade evidence suggests the usefulness of electronic reminders to providers increase uptake [19] and provider education [20].

    Very low grade evidence suggests that inconsistent advice from healthcare providers might pose a barrier to vaccine uptake in this population [21].


    Evidence statement 8: Children

    We identified no high quality RCTs or systematic reviews that investigated interventions, barriers or facilitators for increasing uptake of flu vaccination among children. Cross-sectional studies from the USA and UK investigating parents? attitudes and views provide some low quality evidence which serve as indicators for future research.

    Common reasons why parents choose to have children vaccinated include:
    • prevention of influenza
    • physicians? recommendation
    • reduced influenza symptoms

    Potential reasons why parents may choose not to have children vaccinated include:
    • low perception of the risk of catching the disease
    • concern about safety and efficacy of vaccines
    • flu vaccine containing thiomersal


    Evidence statement 9: Adult population

    Low grade evidence from the USA shows that electronic reminders might help improve flu vaccination rates in adults if they can access the internet and use it regularly [22].

    In one survey (low grade evidence) undertaken in 11 European countries, being older, and being older with a chronic condition is a determinant of vaccine uptake. Countries with high per capita income have significantly higher rates of coverage in adults. Awareness that influenza is a serious illness, advice from a family doctor (in 8 of 11 countries), and the wish not to transmit influenza to family members and friends seem to facilitate uptake.

    Adults who did not feel likely to catch influenza or who had never considered vaccination before were less likely to be vaccinated. Having to pay for vaccines is a barrier, especially in poorer countries [23].


    Background

    The 2009 Council of the European Union Recommendation (Recommendation 2009/1019/EU of 22 December 2009)i on seasonal influenza vaccination encouraged countries to implement measures that would increase seasonal influenza vaccination uptake to at least 75% for defined older age groups, and, if possible, for other risk groups. These targets were intended to be reached by the 2014?2015 winter season.
    Following the Council Recommendation, several key high-risk groups were identified as important for increased coverage of seasonal flu vaccination.

    These are:
    • Older age groups (usually 65 years and older)
    • Pregnant women (not all Member States)
    • Children below two or below five years of age (not all Member States)
    • Healthcare workers (HCWs)
    • Individuals over six months of age with chronic medical conditions, particularly the following:
      • chronic respiratory diseases
      • chronic cardiovascular diseases
      • chronic metabolic conditions
      • chronic renal and hepatic diseases
      • persons with acquired of congenital immunodeficiency
      • persons with a compromised respiratory function
      • persons with morbid obesity

    The outputs from the Vaccine European New Integrated Collaboration Effort (VENICE) project are key to understanding the subsequent developments and trends in influenza vaccination in Europe. The VENICE survey describes aspects of the seasonal influenza immunisation policies implemented in the European Union (EU) Member States, Norway and Iceland, and collects available vaccination uptake data for the risk groups and HCWs.

    The most recent VENICE report [24] covers the 2010?11 influenza season and shows great variation between countries. Vaccination rates for over 65s are highest in the Netherlands at 80.6% as opposed to 1.1% in Estonia.

    Seven countries reported vaccination uptake rates in healthcare workers; it ranged from 14% in Norway to 63.9% in Romania. Only five countries reported on the clinical risk groups; uptake was 29.4% in Portugal and 68.9% in the Netherlands. The coverage in pregnant women was only reported in two countries, 3.6% in Romania, and 36.6% for healthy and 56.6% for at-risk women in England. Portugal reported 82.9% coverage for residents of long-term care stay facilities and Slovakia reported 85.4%; no other countries reported this type of coverage.

    VENICE demonstrates that different systems, protocols and policies are implemented throughout the region with different risk group definitions being used. For example, the World Health Organization Regional Office for Europe (WHO?EURO) [25] priority groups for seasonal influenza vaccination included elderly persons over a nationally defined age limit, irrespective of other risk factors. However, although Norway, Iceland and all the countries in the EU recommend seasonal influenza vaccination of elderly people, the definition of older age groups varies amongst them.
    Most of the countries (19 out of 28) recommend the vaccine for individuals aged 65 and older, but others have lower age criteria. Seven countries recommend vaccinination for children (Latvia, Malta, Austria, Estonia, Poland, Slovenia, Slovakia) but not all of them for all ages of children.

    All 28 countries recommend the vaccination of patients with chronic medical conditions of the heart and lungs, haematological or metabolic disorders, immuno-suppression due to diseases or treatment, and renal disease. But three of the countries exclude those with HIV/AIDS.

    Vaccination is recommended for individuals suffering from hepatic and neurological diseases and for those taking long-term aspirin in 19 countries and in nine countries for those with morbid obesity.

    Healthcare workers are considered a target group for vaccination by most of the countries and nearly half of these countries also recommend the vaccination of poultry industry workers.

    The new report shows that now 19 of the 28 countries recommend the vaccination for all pregnant women and three of them for pregnant women with another clinical risk condition.

    New risk groups were included to the recommendations for influenza vaccine after the influenza pandemic occurred (2009?2010). Nineteen countries added those with neurological diseases and nine countries added morbidly obese individuals.

    Nonetheless, a substantial gap between the official recommendations to vaccinate individuals at risk and the actual vaccination rates in these groups still exist.

    Of all countries responding to the survey, 18 reported that no national action plan (NAP) was adopted in their country and seven countries updated previously developed plans. Two countries reported that a national plan had been adopted. This shows no change compared to the previous VENICE survey.

    Although the VENICE survey collects valuable information about projected changes in national policies, it is not a source of information about how vaccination services are organised or measures taken to promote vaccination uptake within responding countries. Therefore, the present review of the literature seeks to fill a gap in knowledge about successful interventions to improve vaccination coverage in target groups in the region.

    The main focus will be on Europe and English language peer-reviewed published literature, although highly relevant data from elsewhere in the world (notably USA, Canada and Australia) were also included.


    Objectives and key questions

    The main objective was to review critically the evidence on the barriers and drivers of seasonal influenza vaccination coverage in the EU/EEA.

    Key questions addressed in the review are:
    • What are the drivers and barriers for increased seasonal flu vaccination coverage in the various risk/target groups in the 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?

    (...)


    References
    1. Higgins J, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 The Cochrane Collaboration, 2011.
    2. Thomas RE, Russell ML, Lorenzetti DL. Systematic review of interventions to increase influenza vaccination rates of those 60 years and older. Vaccine 2010;28(7):1684?701.
    3. Usami T, Hashiguchi M, Kouhara T, Ishii A, Nagata T, Mochizuki M. Impact of community pharmacists advocating immunization on influenza vaccination rates among the elderly. Yakugaku Zasshi - Journal of the Pharmaceutical Society of Japan 2009;129(9):1063?68.
    4. Onder G, Liperoti R, Bernabei R, Landi F. Case management, preventive strategies, and caregiver attitudes among older adults in home care: results of the ADHOC study. Journal of the American Medical Directors Association 2008;9(5):337?41.
    5. Dexter LJ, Teare MD, Dexter M, Siriwardena AN, Read RC. Strategies to increase influenza vaccination rates: outcomes of a nationwide cross-sectional survey of UK general practice. BMJ Open 2012;2(3).
    6. Crawford VL, O'Hanlon A, McGee H. The effect of patient characteristics upon uptake of the influenza vaccination: a study comparing community-based older adults in two healthcare systems. Age & Ageing 2011;40(1):35?41.
    7. Chiatti C, Barbadoro P, Lamura G, Pennacchietti L, Di Stanislao F, D'Errico MM, et al. Influenza vaccine uptake among community-dwelling Italian elderly: results from a large cross-sectional study. BMC Public Health 2011;11(Journal Article):207.
    8. Jimenez-Garcia R, Hernndez-Barrera V, Rodriguez-Rieiro C, de Andres AL, Miguel-Diez J, Trujillo IJ, et al. Are age-based strategies effective in increasing influenza vaccination coverage?: the Spanish experience. Human vaccines & Immunotherapeutics 2012;8(2):228?33.
    9. La Torre G, Iarocci G, Cadeddu C, Boccia A. Influence of sociodemographic inequalities and chronic conditions on influenza vaccination coverage in Italy: results from a survey in the general population. Public Health 2010;124(12):690?97.
    10. Esposito S, Pelucchi C, Tel F, Chiarelli G, Sabatini C, Semino M, et al. Factors conditioning effectiveness of a reminder/recall system to improve influenza vaccination in asthmatic children. Vaccine 2009;27(5):633?35.
    11. Walter EB, Hellkamp AS, Goldberg KC, Montgomery D, Patterson B, Dolor RJ. Improving influenza vaccine coverage among asthmatics: A practice-based research network study. Journal of Clinical Outcomes Management 2008;15(5):227?34.
    12. Fiks AG, Hunter KF, Localio AR, Grundmeier RW, Bryant-Stephens T, Luberti AA, et al. Impact of electronic health record-based alerts on influenza vaccination for children with asthma. Pediatrics 2009;124(1):159?69.
    13. Lam PP, Chambers LW, MacDougall DM, McCarthy AE. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ Canadian Medical Association Journal 2010;182(12):E542?8.
    14. Rothan-Tondeur M, Filali-Zegzouti Y, Golmard JL, De Wazieres B, Piette F, Carrat F, et al. Randomised active programs on healthcare workers' flu vaccination in geriatric health care settings in France: the VESTA study. Journal of Nutrition, Health & Aging 2011;15(2):126-32.
    15. Chapman GB, Li M, Colby H, Yoon H. Opting in vs opting out of influenza vaccination. JAMA 2010;304(1):43-44.
    16. Rakita RM, Hagar BA, Crome P, Lammert JK. Mandatory influenza vaccination of healthcare workers: a 5-year study. Infection Control & Hospital Epidemiology 2010;31(9):881-88.
    17. Quan K, Tehrani DM, Dickey L, Spiritus E, Hizon D, Heck K, et al. Voluntary to mandatory: evolution of strategies and attitudes toward influenza vaccination of healthcare personnel. Infection Control & Hospital Epidemiology 2012;33(1):63?70.
    18. Mouzoon ME, Munoz FM, Greisinger AJ, Brehm BJ, Wehmanen OA, Smith FA, et al. Improving influenza immunization in pregnant women and healthcare workers. American Journal of Managed Care 2010;16(3):209?16.
    19. Riley M, Galang S, Green LA. The impact of clinical reminders on prenatal care. Family medicine 2011;43(8):560?65.
    20. Panda B, Stiller R, Panda A. Influenza vaccination during pregnancy and factors for lacking compliance with current CDC guidelines. Journal of Maternal-Fetal & Neonatal Medicine 2011;24(3):402?06.
    21. McCarthy EA, Pollock WE, Nolan T, Hay S, McDonald S. Improving influenza vaccination coverage in pregnancy in Melbourne 2010-2011. Australian & New Zealand Journal of Obstetrics & Gynaecology 2012;52(4):334?41.
    22. Wright A, Poon EG, Wald J, Feblowitz J, Pang JE, Schnipper JL, et al. Randomized controlled trial of health maintenance reminders provided directly to patients through an electronic PHR. Journal of General Internal Medicine 2012;27(1):85?92.
    23. Blank PR, Schwenkglenks M, Szucs TD. Vaccination coverage rates in eleven European countries during two consecutive influenza seasons. Journal of Infection 2009;58(6):446?58.
    24. O?Flanagan D, Cotter S, Mereckiene J, Consortium. obotVI. Seasonal influenza vaccination in EU/EEA, influenza season 2010-11. Vaccine Europe New Integrated Collaboration Effort II, 2012.
    25. WHO/Europe. WHO/Europe recommendations on influenza vaccination during the 2011-2012 winter season. . Copenhagen: WHO, 2011.
    26. Cochrane EPOC (Effective Practice and Organisation of Care Group). MECIR (Methodological standards for the conduct of new Cochrane Intervention Reviews), 2012.
    27. National Institute for Health and Clinical E. Methods for the development of NICE public health guidance. 2nd ed, 2009.
    28. Beale SJ, Bending MW, Trueman P, Naidoo B. Should we invest in environmental interventions to encourage physical activity in England? An economic appraisal. The European Journal of Public Health 2012.
    29. Jackson R, Ameratunga S, Broad J, Connor J, Lethaby A, Robb G, et al. The GATE frame: critical appraisal with pictures. Evid Based Med 2006;11(2):35?8.
    30. SIGN (Scottish Intercollegiate Guidelines Network). SIGN 50 (A guideline developer?s handbook). Revised edition. Edinburgh: Scottish Intercollegiate Guidelines Network/HIS, 2011.
    31. Chiatti C, Di Rosa M, Barbadoro P, Lamura G, Di Stanislao F, Prospero E. Socioeconomic determinants of influenza vaccination among older adults in Italy. Preventive Medicine 2010;51(3-4):332?33.
    32. Flood EM, Rousculp MD, Ryan KJ, Beusterien KM, Divino VM, Toback SL, et al. Parents' decision-making regarding vaccinating their children against influenza: A web-based survey. Clinical therapeutics 2010;32(8):1448?67.
    33. Flood EM, Ryan KJ, Rousculp MD, Beusterien KM, Divino VM, Block SL, et al. Parent preferences for pediatric influenza vaccine attributes. Clinical pediatrics 2011;50(4):338?47.
    34. Brown KF, Kroll JS, Hudson MJ, Ramsay M, Green J, Vincent CA, et al. Omission bias and vaccine rejection by parents of healthy children: implications for the influenza A/H1N1 vaccination programme. Vaccine 2010;28(25):4181?85.
    35. Blank PR, Schwenkglenks M, Szucs TD. Disparities in influenza vaccination coverage rates by target group in five European countries: trends over seven consecutive seasons. Infection 2009;37(5):390?400.
    36. Rothan-Tondeur M, Filali-Zegzouti Y, Belmin J, Lejeune B, Golmard JL, de Wazieres B, et al. Assessment of healthcare worker influenza vaccination program in French geriatric wards: a cluster-randomized controlled trial. Aging-Clinical & Experimental Research 2010;22(5-6):450?55.
    37. Lemaitre M, Meret T, Rothan-Tondeur M, Belmin J, Lejonc JL, Luquel L, et al. Effect of influenza vaccination of nursing home staff on mortality of residents: a cluster-randomized trial. J Am Geriatr Soc 2009;57(9):1580?6.
    38. Ahluwalia IB, Singleton JA, Jamieson DJ, Rasmussen SA, Harrison L. Seasonal influenza vaccine coverage among pregnant women: pregnancy risk assessment monitoring system. Journal of Women's Health 2011;20(5):649?51.
    39. Wray RJ, Buskirk TD, Jupka K, Lapka C, Jacobsen H, Pakpahan R, et al. Influenza vaccination concerns among older blacks: a randomized controlled trial. American Journal of Preventive Medicine 2009;36(5):429?34.e6.
    40. Stirling AS, McMenamim J, Cromie D, Patterson T, Robertson C. Evaluation of the under 65 Scottish National Invitation for Flu Pilot (U-SNIFF): Draft interim report, 2012. 2012.
    41. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012; 380, 9836, 37?43
    42. European Centre for Disease Prevention and Control. ECDC scientific advice on seasonal influenza vaccination of children and pregnant women. Stockholm: ECDC, 2012.
    43. Petticrew M, Roberts H. Evidence, hierarchies, and typologies: horses for courses. J Epidemiol Community Health 2003;57(7):527?29.
    44. Ogilvie D, Egan M, Hamilton V, Petticrew M. Systematic reviews of health effects of social interventions: 2. Best available evidence: how low should you go? Journal of Epidemiology and Community Health 2005;59(10):886?92.
    45. Bambra C. Real world reviews: a beginner's guide to undertaking systematic reviews of public health policy interventions. Journal of Epidemiology and Community Health 2011;65(1):14?19.
    46. Bhat-Schelbert K, Lin CJ, Matambanadzo A, Hannibal K, Nowalk MP, Zimmerman RK. Barriers to and facilitators of child influenza vaccine - perspectives from parents, teens, marketing and healthcare professionals. Vaccine 2012;30(14):2448?52.
    47. Flood EM, Block SL, Hall MC, Rousculp MD, Divino VM, Toback SL, et al. Children's perceptions of influenza illness and preferences for influenza vaccine. Journal of Pediatric Health Care 2011;25(3):171?79.
    48. Mills E, Jadad AR, Ross C, Wilson K. Systematic review of qualitative studies exploring parental beliefs and attitudes toward childhood vaccination identifies common barriers to vaccination. J Clin Epidemiol 2005;58(11):1081?8.

    ________

    (i) Standing orders allow professionals who are not physicians (e.g. nurses or pharmacists) to give vaccinations without direct physician involvement at the time of the vaccination.

    (i) The Council of the European Union Recommendation 2009/1019/EU of 22 December 2009 on seasonal influenza vaccination. Available here: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:348:0071:0072:EN:PDF


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