We found low influenza vaccination coverage during the 2018-2019 season in HCW (physicians, nurses, nursing assistants and other paramedical personnel) and non-medical professionals working in NH in France. Uptake varied according to occupational category. Consistent with results from other French and European studies, coverage was highest in physicians (9–11), followed by nurses, other paramedical personnel, non-medical professionals, and nursing assistants. These results showed that professionals in close contact with NH residents, and in particular nurse assistants, are insufficiently vaccinated.
Coverage data for the 2019-2020 season in metropolitan France were compared with those for the 2008-2009 season (overseas data for the latter period were not available) (9). Over the 10-year intervening period, coverage in physicians increased (2008-2009: 60.4% [CI95%: 54.9-65.8] vs. 2018-2019: 75.5% [69.3-81.7]), remained stable in nurses (45.2% [42.8-47.5] vs. 43.1% [39.6-46.7]), decreased in nursing assistants (33.7 [31.8-35.6] vs. 26.9 [24.6-29.2]), and tended to decrease in non-medical professionals (34.2 [32.0-36.3] vs. 28.8 [25.2-32.3]). Data were not collected for other paramedical personnel in 2008-2009. Accordingly, like-for-like comparison of HCW coverage cannot be made. Taking this missing data into consideration, coverage for all HCW combined remained relatively stable (33.6% [31.9-35.4] vs. 31.9% [29.7-34.1]. Differences in coverage according to profession became more pronounced over time. This is a particularly worrying finding, especially for nursing assistants, as they provide direct, close contact care to residents. Moreover, this finding highlights the difficulty of reaching these populations, and underlines the importance of creating tailored prevention messages for professionals working in NH.
The huge controversy surrounding vaccination against influenza in 2010 in France reflected a growing reticence by the French general population about vaccines in general, and led to a plurennial decrease in coverage (12).
Our study highlighted several key findings useful for policymakers to improve influenza vaccination uptake in HCW working in NH. We discuss these findings below.
Providing influenza vaccination free of charge for professionals working in NH significantly improved vaccine coverage. In our study, almost 98% of NH already implemented this measure.
In-house information sessions
The organisation of information sessions for staff in NH helped increase vaccine coverage whether these sessions were collective or individual.
While providing information about influenza vaccines was associated with a significant increase in HCW coverage, this was not the case for providing information about influenza, or information about the individual or collective benefits of vaccination. This result suggests that professionals wait for reliable information about influenza vaccines before deciding whether to get vaccinated or not. Studies elsewhere have shown that believing that the vaccine is effective and unlikely to cause side effects is correlated with higher uptake (13, 14).
Information sessions and providing information about influenza vaccines on vaccine uptake at a national level would very likely lead to significant improvements, since we found that less than 70% of NH in France organised such sessions for staff in the 2018-2019 influenza season or gave information about influenza vaccines.
Media to transmit information
Although over 90% of the NH included had hung up posters to promote influenza vaccination in HCW, this medium had no influence on vaccination in this population. In contrast, using videos or games was associated with more than a 40% increase in HCW vaccination uptake. The success of these media could certainly be linked to the fact that they are better at attracting the attention of professionals because of their originality and because they foster interactive exchanges. It is important to highlight that these tools were only used in 10% of NH.
Having a point of contact in the NH who provided accurate vaccination information was associated with higher uptake in HCW (70%). Nevertheless, only 33% of all the NH included declared having such a person.
The points discussed above highlight that any information disseminated during a vaccination campaign must take into account the following elements: i) provide information on influenza vaccines, ii) use attractive media, and iii) be conveyed by a vaccination point of contact who HCW in the NH trust. Previous studies have shown that HCW can be reluctant to search for information published by national public health institutes because time constraints (15). Furthermore, innovative and original information tools that can be accessed and used directly in NH, as well as train-the-trainer programmes for vaccination points of contact need to be explored. Combining these measures should make it possible to increase vaccine coverage.
In our study, coverage was also higher in NH where a care coordinator was present, and when the director, care coordinator or nurse coordinator supported and was involved in the vaccination campaign.
Higher vaccination rates were observed in private NH (vs. public NH). This finding was already observed for the 2007-2008 season in France (9). Private nursing homes may encourage vaccination of their staff more than public ones. Furthermore, coverage was higher in small (i.e., fewer than 100 beds) NH, which reflects previous findings in France (9). One possible reason for this is management teams in small NH are more committed to their staff’s health: falling ill may lead to HCW absenteeism; compensating for an absent colleague may be more difficult in smaller structures.
Studies on vaccine hesitancy concluded that while knowledge about efficacy and safety are key elements, societal endorsement, support from colleagues and believing that most colleagues had been vaccinated are also important (15, 16).
Finally, vaccine coverage against influenza was much lower in the four overseas territories included than in metropolitan France. Although influenza also circulates in South America and the Caribbean islands, it is possible that HCW in these territories may have felt less at risk or were more reluctant to get vaccinated for this disease. Specific studies are needed to characterise influenza vaccination hesitancy and to set up tailored vaccination campaigns in overseas territories. It is possible that uptake was underestimated for Reunion Island due to the study period, as this territory is located in the southern hemisphere.
Annual influenza vaccination is recommended for HCW worldwide, but uptake remains low in the majority of countries (17, 18). Compulsory influenza vaccination programmes for HCW have led to uptake levels of over 95% (19–21). Currently no country has made influenza vaccination compulsory for HCW at the national level. This issue will be re-examined in France by the Ministry of health in the months to come.
Our study has limitations. First, we only collected aggregated data; individual data such as demographic characteristics, vaccine hesitancy, and knowledge about the influenza vaccine were not collected. Despite a high response rate (certainly in part thanks to the short, easy-to-fill questionnaire used), NH that did not respond to the survey may have been those where HCW vaccination initiatives were the least developed and therefore had potentially lower coverage rates. Second, the questionnaire was self-administered by NH directors, medical or nursing coordinators, and data quality cannot be verified. Finally, recall bias cannot be excluded, although we can assume that is was limited, given the relatively short time interval between the period of vaccination and the study. Estimates of influenza vaccination coverage obtained through this study were close to those observed in the surveillance of clusters of acute respiratory clusters occurred in nursing homes during the 2018-2019 season (influenza vaccination coverage of HCW: 33%) (3).
Influenza vaccination uptake in NH residents was not investigated in this study because it has been reported for many years in France (9), and was confirmed by surveillance data for the 2018-2019 season (87% uptake in NH reporting acute respiratory infection clusters) (3).