1. 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

2. 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 season

3. Coverage varies widely between countries:
VENICE project and trends in influenza vaccination in Europe ( 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%)

4. 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?

5. Evidence selection 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

6. 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

7. 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
Role models – management mandate ignoring social network theory

8. Summary findings Children: Pregnant women: Chronic conditions:
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.

9. 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.

10. 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

12. http://www. health-in-mind. org

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

14. 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