ATTITUDE TOWARDS RECEIVING AN INFLUENZA VACCINATION AMONG
PATIENTS AND VISITORS
IN SUNY UPSTATE MEDICAL UNIVERSITY’S EMERGENCY MEDICINE
DEPARTMENT
by
Christian Conrad Meyer Knutsen
Doctor of Medicine, Pennsylvania State University, 2000
BA, Hamilton College, 1996
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2014
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Christian Conrad Meyer Knutsen
on
March 28, 2014
and approved by
Essay Advisor:
Eleanor Finegold, PhD
Professor of Human Genetics
MMPH Program Acting Director
Graduate School of Public Health
University of Pittsburgh
Essay Reader:
Adam Tobias, MD
Assistant Professor
Department of Emergency Medicine
University of Pittsburgh Medical Center
University of Pittsburgh
______________________________________
______________________________________
ii
Copyright © by Christian Conrad Meyer Knutsen
2014
iii
Eleanor Finegold, PhD
ATTITUDE TOWARDS RECEIVING AN INFLUENZA VACCINATION AMONG
PATIENTS AND VISITORS
IN SUNY UPSTATE MEDICAL UNIVERSITY’S EMERGENCY MEDICINE
DEPARTMENT
Christian Conrad Meyer Knutsen, MPH
University of Pittsburgh, 2014
ABSTRACT
Influenza immunizations are a critical means of preventing illness and death every flu season.
these immunizations are projected to prevent thousands of deaths and save billions of dollars of
productivity every year. The CDC has expanded its’ recommendation for vaccination to include
all persons over 6 months in 2010, but national immunization rates have not surpassed 40% for
all age groups. Expand the availability of flu shots to include non-traditional site has been
recommended. Emergency Departments’ populations of under-immunized patients would be
one such area where expanded immunizations could be targeted. In addition, targeting visitors in
EDs would expand any immunization program. This survey research project evaluated the
baseline influenza vaccination rate of patients and visitors, the percent of unimmunized
individuals planning to be immunized this season and the willingness of these individuals to
receive an influenza vaccination in three different financial offerings: if the flu shot was free, if
the cost was reimbursed by an insurance company, and if the patient or visitor was directly
charged the cost of immunizations. Immunization rates were better than national averages.
Approximately 75% of all persons would agree to a flu shot in the ED if offered for free and
decreasing to just less than 50% if self pay.
Among unimmunized persons, immunization rates
were only 50% if free, suggesting a cognitive barrier, and dropping to 25% if self pay,
iv
suggesting a financial barrier. If a widespread immunization program were offered next flu
season, a large number of patients and visitors could potentially be immunized. Limitations to
the prediction include a low sample size and a suspected high rate of refusal to cooperate with
this survey. Offering flu vaccines in Emergency Medicine, however, would provide a nontraditional site of vaccination, potentially reach a large number of people with structural and
financial barriers to healthcare and be of important public health significance if implemented
either locally or nationally.
v
TABLE OF CONTENTS
1.0
OVERVIEW ................................................................................................................. 1
2.0
METHODS ................................................................................................................... 5
3.0
RESULTS ..................................................................................................................... 7
4.0
DISCUSSION ............................................................................................................. 12
APPENDIX A: UPSTATE ED INFLUENZA VACCINATION SURVEY .......................... 17
APPENDIX B: IRB LETTER.................................................................................................... 18
BIBLIOGRAPHY ....................................................................................................................... 19
vi
LIST OF TABLES
TABLE 1. TOTAL NUMBER OF ADULTS AND CHILDREN SURVEYED DIVIDED INTO
PATIENTS AND VISITORS. ........................... ERROR! BOOKMARK NOT DEFINED.
TABLE 2. PERCENT OF ADULTS AND CHILDREN WITHOUT SEASONAL INFLUENZA
VACCINATION, DIVIDED INTO PATIENTS AND VISITORS ....................................... 8
TABLE 3. PERCENT OF ADULTS AND CHILDREN THAT HAVE NOT RECEIVED AN
INFLUENZA VACCINATION THAT WISH TO HAVE THE INFLUENZA
VACCINATION THIS SEASON, DIVIDED INTO PATIENTS AND VISITORS............. 8
TABLE 4. WILLINGNESS TO RECEIVE AN INFLUENZA VACCINATION WHILE IN
THE EMERGENCY DEPARTMENT. .................................................................................. 9
TABLE 5. WILLINGNESS OF THOSE WITHOUT A SEASONAL INFLUENZA
VACCINATION TO RECEIVE THIS VACCINATION WHILE IN THE EMERGENCY
DEPARTMENT. ................................................ ERROR! BOOKMARK NOT DEFINED.
vii
LIST OF FIGURES
FIGURE 1. PERCENT OF ALL SURVEYED INDIVIDUALS WILLING TO RECEIVING
AN INFLUENZA VACCINATION IN THE EMERGENCY DEPARTMENT BASED ON
PAYMENT OPTIONS, DIVIDED BETWEEN ADULTS AND CHILDREN. .................... 9
FIGURE 2. PERCENT OF ALL SURVEYED INDIVIDUALS WITHOUT A PREVIOUS
SEASONAL INFLUENZA VACCINATION WILLING TO RECEIVE THE
VACCINATION IN THE EMERGENCY DEPARTMENT BASED ON PAYMENT
OPTIONS, DIVIDED BETWEEN ADULTS AND CHILDREN. ...................................... 11
FIGURE 3. WILLINGNESS TO RECEIVE AN INFLUENZA VACCINATION WHILE IN
THE EMERGENCY DEPARTMENT BY PEOPLE WHO HAVE NOT PREVIOUSLY
RECEIVED THE IMMUNIZATION................................................................................... 13
FIGURE 4. PROJECTED NUMBERS OF ED PATIENTS AND VISITORS WILLING TO
RECEIVE AN INFLUENZA VACCINATION ................................................................... 14
viii
1.0
OVERVIEW
Influenza or the flu is a contagious respiratory illness caused by influenza viruses that
typically occurs in annual epidemics from the late fall through the early spring months.
Influenza usually causes mild to moderate symptoms including nasal congestion, rhinorrhea,
fever, and body aches. However, complications from severe infections may lead to urgent
medical care visits, hospitalizations and death as a result of the infection itself or complications
associated with age, pregnancy, underlying cardiopulmonary or other chronic diseases.
Influenza infections have caused a mean of 226,000 annual hospitalizations from 1980 to 20011
and approximately 19,000 annual deaths between 1976 and 1990 increasing to 36,000 annuals
deaths between 1990 and 19992. While young children and adults over 65 most often suffer from
complications, Influenza causes severe morbidity and mortality in all age groups.
Prevention and acute treatment are the foundation of minimizing the impact the flu.
Nonpharmacologic interventions such a handwashing, improved respiratory hygiene, and staying
home when sick are reasonable and inexpensive means of limiting the viruses’ transmission, but
their effect on reducing viral infections is difficult to measure.3,4 Antiretroviral treatment does
mitigate the effects of an acute infection and chemoprophylaxis decreases the spread of the
illness, but use on a widespread population level is not medically feasible or cost effective.
Annual vaccinations against influenza viruses are the most effective strategy to prevent
the flu. For the 2012-2013 influenza season, vaccinations resulted in an estimated 6.6 million
1
fewer illness, 3.2 million fewer outpatient visits, and 79,000 fewer hospitalizations.5 For the
2013-14 season thus far, influenza vaccinations decrease the rate of office visits by 60%.6 An
estimated 17.3% of adverse health outcomes were prevented in recent months, most significantly
be reducing illness and hospitalizations among children 6 months to 4 years old and adults over
65 years.5 Considering the cost of lost earnings due to illness and loss of life is estimated to be
$16.3 billion annually, reducing the burden of influenza infections is of tremendous value.7
The Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on
Immunization Practices (ACIP) has steadily expanded their recommendations for influenza
vaccinations in the last decade. ACIP updated their 2003 recommendation to immunize persons
over 65 years, high risk adults over 50 years and high risk children to include all children 6 to 23
months old in 20048, all adults over 50 years and children 6 to 59 months in 20069, all children
over 6 months in 200810 and finally all persons over 6 months in 2010.11
CDC’s Healthy People
2020 target goals for influenza vaccination rates are over 80% for children and 70% for all
individuals.12
ACIP’s expanded vaccine recommendations have been meant to improve
immunization coverage and decrease disease burden.
Despite efforts to increase vaccination rates, however, the majority of persons do not
receive an annual vaccination.13 Pediatric immunization rates improve modestly from 2009-10 at
43.7% to 2010-11 at 51.0%.
Vaccination rates over this same period, however, remained
statistically unchanged for adults 18-49 years from 29.9% to 30.5% and for all adults staying
near 40%.13
Several barriers may explain persistently low immunization rates far below Healthy
People 2020 goals. Cognitive barriers include beliefs that the flu is not dangerous, concerns the
flu shot causes worse illness than the flu itself, rumors of lack of safety, and lack of knowledge
2
where to get a vaccine. Financial barriers include lack of healthcare insurance, poverty, and
inability to pay for the immunization. Structural barriers include lack of a primary care provider,
inability to travel to physician offices, and lack of other resources that provide the flu shot. All
limit the reach of immunizations to the general population. However, the CDC has specifically
recommended expanded access to vaccinations through nontraditional settings such as schoolbased, community-based and employer-based programs to reduce structural barriers.13
Emergency Medicine has a unique position in regards to influenza prevention. In 2010,
Emergency Departments (EDs) cared for 129 million patients.14 Twenty percent of the United
State’s population visited an ED at least once that year. Of these visits, 112 million patients
were discharged home. Being the healthcare safety net, ED patients often do not have primary
care physicians and are under-immunized.15 Vaccinations of ED patients have been previously
shown to be a cost-effect means of avoiding later hospital admissions for vaccine-preventable
diseases.16,17,18,19,20 ED patients offered an influenza vaccination are much more likely to receive
the shot during their visit than those referred to an outpatient clinic.21 However, Emergency
Physicians do not routinely immunize against respiratory illnesses. Despite the flu’s large
burden of disease, less 1% of all vaccines given in EDs was against influenza.22 All these facts
suggest that Emergency Medicine would be a non-traditional setting for patients with structural
and financial barriers to routine immunizations and an area where significant expansion would
improve the healthcare for a large portion of the population.
No previous studies have quantified the number of visitors of patients in EDs. From
practical experience, most patients have either friends or family with them.
For pediatric
patients, a parent or another adult must be in the room. Offering influenza shots to patients’
visitors may be a novel means of broadening the reach of an ED vaccination program. The
3
medical evaluation needed is minimal and the vaccination is amenable to a protocolization for
easily delivery.
Since the CDC’s expanded influenza vaccination recommendations in 2010 to include all
persons over 6 months old, no other study has evaluated the willingness of ED patients to receive
an influenza vaccination. No previous known projects have considered an influenza vaccination
program for ED visitors. This project surveys ED patients and visitors regarding their influenza
immunization status, their plans to receive an immunization as an outpatient, and their
willingness to receive an influenza vaccination in three specific situations: if the cost of the shot
was free, if reimbursed by their insurance carrier, and if provided at a cost to the patient.
4
2.0
METHODS
SUNY Upstate Medical University is the level 1 tertiary care trauma center in Syracuse, New
York, that serves the entire Central New York Region in addition to areas north to the Canadian
border and south to the Pennsylvania border. The Department of Emergency Department (DEM)
has two Emergency Departments, one at its Community Campus that cared for approximately
25,000 patients and another at its Downtown Campus that cared for approximately 67,000
patients in 2013. The Downtown Campus, the research site for this project, sees approximately
85% adult and 15% pediatric patients every year. Adult patients have an admission rate of 25%
and pediatric patients a rate of 8%.
From December 15, 2013, to February 31, 2014, a convenience sample of patients and
their accompanying visitors were surveyed regarding their willingness to receive an influenza
vaccination during their visit to the ED. The patients and visitors were interviewed by academic
associates, research volunteers who work in the ED and help conduct observational and survey
research projects. All patients and visitors over 6 months old, whether they were friends or
family, were included in this survey. Children were only surveyed in the presence of an adult
who could agree to the survey and answer the survey questions. Verbal consent was obtained by
participants. Patients who were critically ill, immobilized on a long back board, intoxicated or a
danger to themselves or others and/or under a safety watch were excluded from this survey. The
5
visitors of these patients were also excluded. If academic associates were unsure if a patient met
exclusion criteria, they sought clarification from the patient’s nurse or physician.
All subjects were asked their age, if they were the patient or a visitor, and if they had an
influenza vaccination during this flu season.
For persons who had not had an influenza
vaccination, subjects were surveyed if they planned on receiving one this season. All subjects
were also asked if they would be willing to receive an influenza vaccination in the ED in three
theoretic situations: if the influenza vaccine was given free, if the vaccine cost would be
reimbursed by their insurance carrier, and if they had to pay for the vaccination out of pocket.
Respondents that were visiting the ED together were recorded in groups. Appendix A is a copy
of the survey instrument used to interview subjects.
SUNY Upstate Medical University’s Institutional Review Board (IRB) reviewed this
project, determined this survey project did not meet the definition of human subject research
according to federal regulations and issued a letter stating that no further IRB review was
necessary (Appendix B).
Survey answers were entered into an excel spreadsheet and descriptive statistics used to
analyze the data.
6
3.0
RESULTS
For this project, 992 total subjects were surveyed. The subjects included 352 patients (35%) and
640 visitors (64%) in 501 groups. Visitors made up almost two-thirds of this survey study and
outnumbered patients nearly two to one. This finding would be consistent with patients having
on average two visitors with them. The total number of adults and children surveyed are
described in Table 1. The average age of all those surveyed was 35.3 years with the average age
of surveyed adults 35.3 years old and of children 11.3 years old.
Table 1. Total number of adults and children surveyed divided into patients and visitors.
Total Surveyed
(% of total)
Patients
(% of total)
Visitors
(% of total)
Adults
818
(82%)
291
(29%)
527
(53%)
Children
174
(18%)
61
(6%)
113
(11%)
The percentage of all subjects who had no received a seasonal influenza vaccination was
40%. The percent of adults without an influenza vaccination was 42% and of children was 30%.
The breakdown of adults and children as patients and visitors is described in Table 2.
7
Table 1. Percent of adults and children without seasonal influenza vaccination, divided into patients and
visitors.
Adults (n=818)
Children (n=174)
42%
(341)
30%
(52)
14%
(112)
28%
(229)
10%
(17)
20%
(35)
Percent Without
Influenza Vaccination
(n)
Percent of Patients
(n)
Percent of Visitors
(n)
Of all surveyed subject who do not have an influenza vaccination, 49% (194) plan on
receiving an influenza vaccination this season. This group included 51% of unvaccinated adults
(173) and 40% of unvaccinated children (21). The breakdown of these adults and children as
patients and visitors is described in Table 3.
Table 2. Percent of adults and children that have not received an influenza vaccination that wish to have the
influenza vaccination this season, divided into patients and visitors.
Percent Unvaccinated That
Desire Vaccination (n)
Percent of Patients
(n)
Percent of Visitors
(n)
Adults
51%
(173)
47%
(53)
52%
(120)
Children
40%
(21)
29%
(5)
46%
(16)
The willingness of subjects to receive an influenza vaccination in the ED was highest
when the theoretical flu shot was offered for free and was significantly less if the shot would be
offered at a charge to the patient (Table 4). As shown in table 3, 50% of adults and 40% of
children had planned on being vaccinated this season. If the shot had been offered for free, those
willing to have the vaccination jumped to 75% in both adults and children. These numbers were
8
similar in both the patient and visitor populations. Even if a charge was asked at the time of
service, nearly 50% would still desire the vaccination (Figure 1).
Table 3. Willingness to receive an influenza vaccination while in the Emergency Department.
Adults
All Surveyed
Percent If Free (n)
Percent if Insurance
Reimbursed (n)
Percent if Self Pay (n)
Patients
Percent If Free (n)
Percent if Insurance
Reimbursed (n)
Percent if Self Pay (n)
Visitors
Percent If Free (n)
Percent if Insurance
Reimbursed (n)
Percent if Self Pay (n)
Children
818
75% (616)
63% (513)
174
76% (133)
65% (113)
48% (392)
291
77% (224)
62% (180)
45% (79)
61
74% (45)
61% (37)
51% (147)
527
74% (392)
63% (333)
48% (29)
113
78% (88)
67% (76)
46% (245)
44% (50)
Figure 1. Percent of all surveyed individuals willing to receiving an influenza vaccination in the
Emergency Department based on payment options, divided between adults and children.
9
A target demographic in the ED would be those patients and visitors who had not
previously had a influenza vaccination. Of these individuals, those willing to receive the
vaccination drops to just below 60% if free and down to near 30% if offered at a charge (Table 5
and Figure 2).
Table 4. Willingness of those without a seasonal influenza vaccination to receive this vaccination while in
the Emergency Department.
Adults
All Surveyed Without
Seasonal Influenza
Vaccination
Percent If Free (n)
Percent if Insurance
Reimbursed (n)
Percent if Self Pay (n)
All Patients Without Seasonal
Influenza Vaccination
Percent If Free (n)
Percent if Insurance
Reimbursed (n)
Percent if Self Pay (n)
All Visitors Without Seasonal
Influenza Vaccination
Percent If Free (n)
Percent if Insurance
Reimbursed (n)
Percent if Self Pay (n)
Children
341
52
59% (201)
46% (157)
58% (30)
44% (23)
29% (99)
112
25% (13)
17
58% (65)
45% (50)
47% (8)
35% (6)
28% (31)
229
29% (5)
35
59% (136)
47% (107)
63% (22)
49% (17)
30% (68)
23% (8)
10
Figure 2. Percent of all surveyed individuals without a previous seasonal influenza vaccination willing to
receive the vaccination in the Emergency Department based on payment options, divided between adults
and children.
Examining groups, 290 responses came from 2 or more connected people. Of these
groups, 20% all had no Shot, 41% all had shot, and 39% was a mix. When looking at agreement
to the patient, only 208 group included responses from a patient and family/visitor and, in these
cases, 19% had a different immunization status as patient, 62% were the same as patient and
19% were mixed.
11
4.0
DISCUSSION
The percent of unimmunized individuals in the adult and pediatric populations were
better than national trends.13 Our pediatric population was better immunized than the national
average at 70% versus 50%. Our adult population was immunized at a rate of 60% versus the
national average of 40%.
The percent of visitors and patients willing to receive an influenza vaccination in all
models was roughly equal. Considering they are in the ED for an illness or injury, patients were
expected to be less likely to agree to an influenza vaccine and its side effects while recovering
from the injury or illness that brought them to the department.
An emergency department influenza vaccination program (EDIVP) must be to reach
people that would not otherwise be immunized. This survey does not explore the reasons why
individuals would not want the flu shot. Most can be assumed to healthcare barriers described
previously. Overcoming cognitive barriers presumably would be more than an EDIVP could
address. These 40% of unvaccinated persons who would not agree to the flu shot even if free of
charge may have these cognitive barriers (Figure 2). People’s plan to have a seasonal flu shot
strongly impacts their willingness to have an immunization in the ED and also suggests strong
cognitive barriers (Figure 3). That being said, almost 20% would still be immunized if the shot
were free even if they did not plan to receive it elsewhere.
12
Figure 3. Willingness to receive an influenza vaccination while in the Emergency Department by people
who have not previously received the immunization.
Of persons planning to have the flu shot and had not received one previously, 95% would
agree to one in the ED if free. This finding suggests that these persons have not had access to an
immunization previously. When the number drops to 49% in the self pay group, a financial
barrier is suggested. An EDIVP is strongly likely to address structural barriers and, if given at
no cost, financial barriers as well.
The results of this survey project allows for extrapolation of a widespread influenza
vaccination program in Upstate’s ED. In 2013, approximately 43,500 adult patients and 23,500
pediatric patients were evaluated in the Downtown Campus’ ED. An assumption can be made
that only discharged patients would be well enough to receive an influenza vaccination.
13
Historically, an average of 75% of adult patients and 92% of pediatric patients are discharged
and would equal 2,750 adult and 1,500 pediatric discharges per month. With the flu season
lasting from October to February, 13,500 adults and 7,500 children are discharged during the flu
season. If vaccinations were provided with a 75% acceptance rate, approximately 10,000 adult
and 5,600 pediatric patients could be offered flu shots.
If given with self pay at a 50%
acceptance rate, 6,750 adult and 3,750 pediatric patients would be vaccinated.
No studies have explored the possibility of vaccinating ED visitors against the flu. In our
survey, approximately 80% more visitors were surveyed than patients (65% vs. 35%) and had a
similar willingness to receive a flu shot as patients. Assuming 24,000 adult and 13,500 pediatric
visitors, 18,225 adults and 10,125 children could be immunized in a free shot model and 12,150
adult and 6,750 children in a self-pay model program.
Figure 4. Projected numbers of ED patients and visitors willing to receive an influenza vaccination
14
An influenza vaccination program for patients and visitors at Upstate’s ED could reach
roughly 44,000 people using the free vaccination model and 29,400 people with a self-pay
vaccination model. However, several factors may make the exact number of immunizations
provided in a real project (Figure 4).
Several limitations may decrease the actual number of immunizations provided. The
sample size of patients surveyed was small compared to the actual emergency department
volume. Of the adult patients discharged in the Emergency Department during the study period,
only 4% were surveyed. For all discharged pediatric patients, only 2% were surveyed. This
small sample size may make generalization to a widespread program difficult. Part of the reason
for the small sample size was patients were subjects’ refusal to complete the survey. Research
associates found many persons they approached were focused on their ED visit and did not want
to answer any questions. The number refusing to complete the survey was not recorded and may
have better created a prediction for a widespread immunization program assuming willingness to
answer questions is equivalent to receiving an immunization,
Even among discharged patients, many may not want a shot during their visit. Patients
with febrile illnesses, gastrointestinal illness or mild trauma visits may not want to deal with the
side effects of the immunization during their recovery.
Providing an immunization program just before and during the early months of flu
season, however, may increase the number of immunizations. Early in the season, many patients
may not have had an immunization from their primary care provider or another immunization
provider. Many patients may be more receptive early in the season.
15
In addition, Upstate’s Emergency Department has an increased census by 5% every year.
An effective immunization program would reach an expected larger number of patients and
visitors every year.
Offering immunizations to visitors is an unique possibility. Visitors can be presumed to
be well and not have the medical or trauma illnesses that would make patients less willing to
receive the immunization. Providing medical care to individuals not registered in the department
and potentially charging or billing them for a service would face significant administrative
barriers. However, the number of visitors exceeds the number of patients in this survey, they are
willing to receive the immunization while in the department and would greatly improve the
impact of an EDIVP.
16
APPENDIX A: UPSTATE ED INFLUENZA VACCINATION SURVEY
17
APPENDIX B: IRB LETTER
18
BIBLIOGRAPHY
1
Thompson WW, Shay DK, Weintraub E, et al. Influenza-associated hospitalizations in the United
States. JAMA 2004; 292: 1333--40.
2
Thompson WW, Shay DK, Weintraub E, et al. Mortality associated with influenza and respiratory
syncytial virus in the United States. JAMA 2003;289:179--86.
3
Bell DM. Non-pharmaceutical interventions for pandemic influenza, national and community
measures. Emerg Infect Dis 2006;12:88--94.
4
Aiello AE, Coulborn RM, Aragon TJ, et al. Research findings from nonpharmaceutical intervention
studies for pandemic influenza and current gaps in the research. Am J Infect Control 2010;38:251--8.
5
Estimated influenza illnesses and hospitalizations averted by influenza vaccination - United States,
2012-13 influenza season. (2013). MMWR. Morbidity and Mortality Weekly Report, 62(49), 997–
1000.
6
Flannery, B., Thaker, S. N., Clippard, J., Monto, A. S., Ohmit, S. E., Zimmerman, R. K., … Fry, A.
M. (2014). Interim estimates of 2013-14 seasonal influenza vaccine effectiveness - United States,
February 2014. MMWR. Morbidity and Mortality Weekly Report, 63(7), 137–42.
7
Molinari, N.-A. M., Ortega-Sanchez, I. R., Messonnier, M. L., Thompson, W. W., Wortley, P. M.,
Weintraub, E., & Bridges, C. B. (2007). The annual impact of seasonal influenza in the US:
measuring disease burden and costs. Vaccine, 25(27), 5086–96.
8
Harper SA, Fukuda K, Uyeki TM, Cox NJ, Bridges CB; Centers for Disease Control and Prevention
(CDC) Advisory Committee on Immunization Practices (ACIP). Prevention and control of influenza:
recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm
Rep. 2004;53(RR-6):1–40
9
Smith NM, Bresee JS, Shay DK, Uyeki TM, Cox NJ, Strikas RA; Advisory Committee on
Immunization Practices. Prevention and control of influenza: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006;55(RR-10):1–42
10 Fiore AE, Shay DK, Broder K, et al; Centers for Disease Control and Prevention (CDC); Advisory
Committee on Immunization Practices (ACIP). Prevention and control of influenza: recommendations
of the Advisory Committee on Immunization Practices (ACIP), 2008. MMWR Recomm Rep.
2008;57(RR-7):1–60
11 Fiore, A. E., Uyeki, T. M., Broder, K., Finelli, L., Euler, G. L., Singleton, J. A., … Cox, N. J. (2010).
Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on
Immunization Practices (ACIP), 2010. MMWR. Recommendations and Reports : Morbidity and
Mortality Weekly Report. Recommendations and Reports / Centers for Disease Control, 59(RR-8), 1–
62.
19
12 Centers for Disease Control and Prevention. Health People 2020 Objective Topic Areas. Retrieved
from http://www.healthypeople.gov/2020/topicsobjectives2020/pdfs/Immunization.pdf on April 10,
2014.
13 McIntyre, A. F., Gonzalez-Feliciano, A. G., Bryan, L. N., Santibanez, T. A., Williams, W. W., &
Singleton, J. A. (2013). Seasonal influenza vaccination coverage - United States, 2009-10 and 201011. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C. : 2002), 62
Suppl 3, 65–8.
14 Centers for Disease Control and Prevention. Emergency Department Visits. Available at
http://www.cdc.gov/nchs/fastats/ervisits.htm. Accessed April 11, 2014.
15
Cunningham, S. J. (1999). Providing immunizations in a pediatric emergency department:
underimmunization rates and parental acceptance. Pediatric Emergency Care, 15(4), 255–9.
16 Slobodkin D, Kitlas JL, Zielske PG. A test of the feasibility of pneumococcal vaccination in the
emergency department. Acad Emerg Med. 1999; 6:724–7.
17 Slobodkin D, Kitlas J, Zielske P. Opportunities not missed–systematic influenza and pneumococcal
immunization in a public inner-city emergency department. Vaccine. 1998; 16:1795–802.
18 Slobodkin D, Zielske PG, Kitlas JL, McDermott MF, Miller S, Rydman R. Demonstration of the
feasibility of emergency department immunization against influenza and pneumococcus. Ann Emerg
Med. 1998; 32:537–43.
19 Stack SJ, Martin DR, Plouffe JF. An emergency department-based pneumococcal vaccination
program could save money and lives. Ann Emerg Med. 1999; 33:299–303.
20 Wrenn K, Zeldin M, Miller O. Influenza and pneumococcal vaccination in the emergency
department: is it feasible? J Gen Intern Med. 1994; 9:425–9.
21 Pappano, D., Humiston, S., & Goepp, J. (2004). Efficacy of a pediatric emergency department-based
influenza vaccination program. Archives of Pediatrics & Adolescent Medicine, 158(11), 1077–83.
22
Pallin, D. J., Muennig, P. A., Emond, J. A., Kim, S., & Camargo, C. A. (2005). Vaccination practices
in U.S. emergency departments, 1992-2000. Vaccine, 23(8), 1048–52.
doi:10.1016/j.vaccine.2004.06.053
20