Suboptimal influenza vaccine uptake among healthcare workers in a regional reference hospital in Spain, 2017–2018. Need for new approaches

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Need for new approaches" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "11" "paginaFinal" => "16" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "R. Ruiz-Montero, R. Ortiz-González Serna, B.R. Guzmán-Herrador, J.L. Barranco Quintana, F.J. Gavilán León, I. Salcedo Leal, R. Torcello Gaspar, M.J. Romero Muñoz, C. Díaz Molina" "autores" => array:9 [ 0 => array:3 [ "nombre" => "R." "apellidos" => "Ruiz-Montero" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Ortiz-González Serna" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:4 [ "nombre" => "B.R." 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"apellidos" => "Díaz Molina" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Gestión Clínica de Medicina Preventiva y Salud Pública, Hospital Universitario Reina Sofía, Córdoba, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nivel subóptimo de adherencia a vacunación antigripal entre los profesionales sanitarios en un hospital regional de referencia en España, 2017–2018. Necesidad de nuevos enfoques" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1664 "Ancho" => 2538 "Tamanyo" => 257582 ] ] "descripcion" => array:1 [ "en" => "Influenza incidence in the hospital's catchment area and distribution of vaccinated HCW and influenza isolated patients per week. Influenza season 2017, 2018. 1Email sent to heads of units. 2Publication of the banner on the hospital's website. 3Oral reminder in the daily meetings between the heads of units and the hospital management." ] ] ] "textoCompleto" => "IntroductionWHO recommends annual influenza vaccination for healthcare workers (HCWs)<a class="elsevierStyleCrossRefs" href="#bib0110">1,2</a> to prevent them from becoming part of the transmission cycle and spreading the infection to their patients. Health care associated influenza has a more severe course compared to patients with community-acquired influenza<a class="elsevierStyleCrossRefs" href="#bib0120">3,4</a> and several publications have documented influenza outbreaks in hospitals with HCWs involved.<a class="elsevierStyleCrossRefs" href="#bib0130">5,6</a> Healthcare associated influenza can generate additional costs by increasing the days of stay and treatments.<a class="elsevierStyleCrossRef" href="#bib0140">7</a> In addition, vaccination aims to protect HCWs from being infected through patients.<a class="elsevierStyleCrossRef" href="#bib0115">2</a> In 2009, the European Union (EU), following WHO recommendations, set a goal of 75% vaccines uptake among risk groups.<a class="elsevierStyleCrossRef" href="#bib0145">8</a>In Spain, annual influenza vaccination is recommended for HCWs at primary and hospital care level, both public and private. This recommendation is especially important for those HCWs who have close contact with high risk patients, such as people over 65 or those with chronic diseases.<a class="elsevierStyleCrossRef" href="#bib0115">2</a> The Regional Ministries of Health at the Autonomous Community level are asked to notify every year to the National Ministry of Health influenza vaccination coverage reached in all risk groups, including HCWs. However, the suboptimal registration or lack of standardization of available vaccination registries at the healthcare facility level makes hard to get a complete national picture. In any case, the vaccination coverage in HCWs in Spain is estimated to be around 15–25%, far from targets recommended by the WHO and the EU.<a class="elsevierStyleCrossRef" href="#bib0115">2</a> The Inter-territorial Board of the National Health System set a vaccination coverage of 40% in HCWs<a class="elsevierStyleCrossRef" href="#bib0150">9</a> as the goal for the 2017–2018 season.HCW's influenza vaccine coverage at our hospital has not been monitored in a systematic way in previous seasons. We developed a vaccination registry during the 2017/18 vaccination campaign to better follow up the vaccine uptake during the season, to have a starting point for measuring trends in future seasons and identify factors that could influence vaccine uptake. Communication activities were planned and conducted to promote de campaign.Material and methodsInfluenza vaccination campaign at our hospital. Vaccine registration and communication strategiesDuring the 2017/18 season, the Unit of Preventive Medicine and Public Health (UPMPH) was responsible for planning and conducting the influenza vaccination campaign targeting HCWs in our hospital. Our regional university hospital has a catchment area of more than 1,100,000 people. It has 1100 beds and around 4400 HCWs. Shortly before the official start of the influenza vaccination campaign the UPMPH received the vaccines from the Hospital Pharmacy Unit. During the first few weeks of the campaign, a two-hour consultation (08: 30–10:30 am) with one nurse was set up for vaccination of HCWs. In addition, the vaccine was always offered to any HCW who asked for it during working hours, even outside of those two hours range.Each HCW being vaccinated at our unit was asked for their professional profile (administration staff, hospital attendant, nursing assistant, nurse, physician, physician under training/medical resident, and other health technician) and working unit (44 units). The information was collected in an aggregated way in a paper sheet during the consultation and transferred to an electronic sheet at the end of each day. In addition, each vaccination was registered individually, with the personal ID of each worker, and vaccine batch in “DirayaVacunas”, the Vaccine registry of the Regional Ministry of Health.We conducted activities to promote the vaccination campaign: several days before the official start we placed an informative sign at the UPMPH door announcing the campaign. On week 45/2017, three weeks after the campaign had started, we circulated an email with a preliminary uptake analysis to all heads of unit asking them to encourage their staff to get vaccinated. During week 46/2017, we posted a banner at the hospital's official website encouraging vaccination with a photograph of HCWs. During week 51/2017 several oral reminders were made during the daily meetings between head of units and the hospital management.Data analysisWe conducted a descriptive analysis by week, HCW profile and working unit. The Human Resources Unit provided us with the total number of HCWS by working unit and professional profile in the hospital, to be able to calculate proportions.In addition, we performed two Chi-square tests to determine whether the professional profile and working unit influenced vaccine uptake. The working unit was grouped in four categories, based on the Portfolio document of Specialized Services of the Regional Health Service: (1) Medical: Allergology, Gastroenterology, Cardiology, Endocrinology, Hematology, Internal Medicine, Infectious diseases, Intensive Medicine, Nuclear Medicine, Nephrology, Pneumology, Neurology, Medical Oncology, Radiation Oncology, Pediatrics, Rehabilitation, Rheumatology, Mental Health, Emergency and Palliative Care. (2) Medical-Surgical: Anesthesia, Cardiovascular Surgery, General Surgery, Maxillofacial Surgery, Pediatric Surgery, Plastic Surgery, Thoracic Surgery, Dermatology, Neurosurgery, Obstetrics and Gynecology, Ophthalmology, Otolaryngology, Traumatology and Orthopedics and Urology. (3) Diagnostics: Clinical Analysis, Pathology, Immunology, Microbiology, Radiodiagnosis and Clinical Neurophysiology). (4) General: Pharmacy, Physics and Radiological Protection, Preventive Medicine and Public Health and Occupational Medicine.We checked whether changes in influenza incidence in the area influenced the perception of risk among HCWs, increasing vaccine uptake. To explore this, we used weekly influenza incidence data in our province, published weekly by the Sentinel Influenza Surveillance System of the Regional Ministry of Health (<a href="https://www.juntadeandalucia.es/organismos/saludyfamilias/areas/salud-vida/vigilancia/paginas/vigilancia-transmisibles.html">https://www.juntadeandalucia.es/organismos/saludyfamilias/areas/salud-vida/vigilancia/paginas/vigilancia-transmisibles.html</a>). As a proxy for the burden of influenza admissions in our hospital we used the cumulative number of patients admitted under droplet precautions due to influenza by week. The analysis was conducted with Microsoft Excel and R studio.ResultsThe 2017–2018 vaccination campaign officially began on Monday, October 23, 2017 (week 42/2017). The end of the campaign was marked by the decline of the epidemic curve under the epidemic threshold which occurred on Saturday, March 3, 2018 (week 09/2018). The vaccine was available at UPMPH during the entire period.A total of 895/4401 HCWs were vaccinated (20.3%) at our Unit. The number of vaccines that were administered peaked on week 44/2017 (226 doses administered), followed by a downward trend until the beginning of January, except for two small vaccination peaks on weeks 48 and 51/2017 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Only 9% of the units (4/44) exceeded 40% vaccination uptake, fulfilling the objective of the National and Regional Ministry of Health. Thirty four percent of the units (15/44) reached between 20% and 39% uptake and more than half (57%; 25/44) had less than 20%. The vaccine coverage was 22.2% in medical units, 21.2% in diagnostic and general units and 17% in medical-surgical units (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). By professional profile, physicians (32%), and medical residents (25%) had the highest percentages (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). None of the professional profiles reached the goal of the Regional/National Ministry of Health. A statistically significant relationship was found between vaccine uptake and grouped working unit (p<0.01) and professional profile (p<0.001).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The largest number of vaccinations occurred at the beginning of the campaign (week 44/2017), much earlier than the main peak of the influenza season in our province, which occurred on week 51/2017 (467.5 cases per 100,000 inhabitants). The first patient isolated under droplet precautions with influenza was admitted at the hospital on week 48/2017. Since then, the number of isolated patients under droplet precautions with influenza had an increasing trend until week 02/2018 (with 105 isolated patient-days) and then slowly decreased until week 16/2018 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The first and the main peak of the epidemic was reflected in the hospital by a large increase in patients isolated under droplet precautions and a slight increase in vaccinations in HCWs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).The email sent to heads of units (1, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and the inclusion of the banner on the hospital's website (2, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) did not influence vaccinations. There was a slight increase in vaccination uptake coinciding with the oral reminder in the daily meetings between the heads of units and the hospital management (3, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).DiscussionThe design of a vaccination registry made feasible a deeper follow-up and analysis of the influenza vaccination campaign among HCWs at our hospital during the 2017–2018 season and will be very useful to measure trends during the next years. The implementation of a similar type of registry, simple, timely and with high quality denominators, in other hospitals could help to obtain a clearer national picture of vaccine uptake among HCWs. Our results indicate that vaccine coverage of HCWs in our hospital this season has been suboptimal, with a global vaccination uptake of 20.3%. This is far from the 40% marked by the Regional/National Ministry of Health. However, it is within the average vaccination adherence estimated in Spain (15–25%).<a class="elsevierStyleCrossRef" href="#bib0115">2</a> Both lower and higher percentages have been described by other studies in Spain.<a class="elsevierStyleCrossRefs" href="#bib0155">10–12</a>We found a statistically significant relationship between vaccine uptake and the professional profile or the working unit category. We observed that a clear majority of HCWs get vaccinated at the beginning of the campaign. The period in which the first and the main influenza peak occurred led to a slight increase in the vaccination of HCWs, which we believe could be due to an increased perception of risk. The number of patients isolated under droplet precautions with influenza, and the incidence of influenza was much higher after week 51/2017, but this did not trigger a new peak in vaccinations. This seems to indicate that the majority of HCWS who get vaccinated do so out of self-awareness at the beginning of the campaign and not because of risk perception. The communication strategies conducted during the campaign had no or very little effect in vaccinations. More intense communication activities, such us videos including clear messages displayed at the hospital screens and social media, or additional vaccination points in the different hospital buildings, as suggested in other studies,<a class="elsevierStyleCrossRef" href="#bib0170">13</a> could have an impact and could be considered as an improvement and evaluated for future campaigns.We acknowledge some limitations in the interpretation of our results. First, we could somehow be underestimating the vaccine uptake since a limited number of HCWs could have chosen to be vaccinated at their primary care center and would have not been registered in our Unit. We believe this number to be rather low as it is easier for HCWs to be vaccinated during working hours at the hospital than asking for an appointment in their primary health care center. We did not collect information on age or years of working experience, which could have also influenced vaccination. It would have been interesting to know which proportion of HCWs belong to an additional vulnerable group (e.g. chronic disease or close contact with a person with chronic pathology) and evaluate the reason that had more weight for these HCWs to ask for the vaccine.It is difficult to compare our estimates with other countries since not all monitor influenza vaccine uptake in the different risk groups, making difficult to establish trends in each country or region. With the aim of exploring this issue, the European Center for Disease Prevention and Control (ECDC), regularly publishes a technical report with a description of influenza vaccination recommendations and uptake in the EU Member States. The last published report has been that of the 2015–16 and 2015–16 flu seasons.<a class="elsevierStyleCrossRef" href="#bib0175">14</a> The report presents the results of the analysis of an electronic questionnaire that was distributed to the national focal points for influenza surveillance in the different Member States. In 29 of the 30 countries that responded, influenza vaccination was recommended in HCWs.<a class="elsevierStyleCrossRef" href="#bib0175">14</a> The coverage among HCWs was known in 12 Member States and ranged from 15.6% to 63.2%.<a class="elsevierStyleCrossRef" href="#bib0175">14</a> The report shows a wide variability within the continent, although it does not include information on the possible reasons that may influence this greater or lesser success of the vaccination campaigns.ECDC has recently warned about the low acceptance of influenza vaccine in Europe and encourages Member States to analyze the reasons why people belonging to risk groups, such as HCWs, decline vaccination.<a class="elsevierStyleCrossRef" href="#bib0175">14</a> Very few countries have specific data that explain the reasons for the low and variable HCWs’ adherence to vaccination, as well as attitudes, knowledge and practices toward the vaccine. Cross-sectional studies carried out in Italy, Spain and Germany estimated that the misconceptions related to the influenza vaccine in health HCWs are related to low risk perception, skepticism on the effectiveness and safety of the vaccine and general disinformation.<a class="elsevierStyleCrossRefs" href="#bib0180">15–20</a> However, there is little information on whether the reasons for non-vaccination and the level of knowledge and awareness vary according to the level of healthcare provided and if there are significant differences that require different intervention programs adapted to different professional profiles.ECDC and the studies mentioned above recommend enhancing vaccination communication strategies and education by implementing innovative information campaigns to eliminate barriers to vaccine acceptance. However, there are very few studies that assess the effectiveness of such interventions, and whether such effectiveness varies by context. A review published in 2013<a class="elsevierStyleCrossRef" href="#bib0210">21</a> analyzed interventions that had been used to increase adherence to influenza vaccination in HCWs. The review concluded that a successful intervention should have different comprehensive intervention packages, well supported by the hospital management, with dedicated staff and communication and promotion strategies with messages directed and adapted to the different professional profiles.ConclusionsLow adherence to influenza vaccination by HCWs is an international public health problem. In our hospital, as in Spain and other European Member States, the current institutional campaign, seem to have low effectiveness and a very modest impact, with vaccination levels far from those recommended by the WHO. Therefore, we consider the need to develop studies to better understand the reason for the suboptimal vaccination. Only then, intervention programs with innovative communication, education, training and information exchange strategies targeting different professional profiles could be planned conducted and evaluated.Author contributionsAll authors have been involved in the design, daily development and management of the vaccination campaign and data collection. CDM and MJRM have coordinated the vaccination campaign. RRM and ROGS have conducted the analysis and interpretation of the results. BGH, RRM, ROGS have drafted the manuscript. BGH has coordinated the manuscript drafting and interpretation of results. All authors have provided comments to the initial draft approved the last version for publication.FundingThis research has not received specific support from public sector agencies, business sector or non-profit entities.Conflict of interestAll authors were health workers from the Preventive Medicine Unit at the Reina Sofia University Hospital while the study was conducted. The activities described in this study are included within the terms of reference of the Unit. BGH and JBQ have received payment by Sanofi Pasteur for teaching activities." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1358185" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion and conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1249121" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1358184" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión y conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1249122" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Influenza vaccination campaign at our hospital. Vaccine registration and communication strategies" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Data analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Author contributions" ] 10 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-01" "fechaAceptado" => "2019-12-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1249121" "palabras" => array:3 [ 0 => "Influenza vaccine" 1 => "Vaccine uptake" 2 => "Healthcare workers" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1249122" "palabras" => array:3 [ 0 => "Vacuna contra la influenza" 1 => "Absorción de la vacuna" 2 => "Trabajadores de la salud" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionSpanish figures on Influenza vaccine uptake among health care workers (HCWs) are not well known. For the 2017/18 campaign, the Spanish Ministry of Health established a minimum goal of 40%. HCWs’ uptake at our hospital has not been measured in previous years. During the 2017/2018 season we enhanced the follow up of the vaccination campaign in our hospital. MethodsWe set up a vaccination registry including working unit and professional profile. We conducted a descriptive and bivariate analysis. We checked whether influenza incidence in the area and the number of influenza patients admitted with influenza in the hospital influenced vaccination. Communication activities were conducted to promote the campaign. ResultsThe campaign lasted from week 42/2017 to 09/2018. A total of 895/4401 HCWs were vaccinated (20.3%). Only 9% of the units (4/44) exceeded 40% vaccination uptake. The number of administered vaccines peaked on week 44/2017, before the main epidemics wave started. A statistically significant relationship was found between vaccine uptake and working unit and professional profile. Communication strategies during the campaign had no effect in vaccine uptake. Discussion and conclusionOur registry made feasible a situation analysis of vaccine uptake among HCWs at our hospital and will be useful to measure future trends. HCWs vaccine uptake has been suboptimal during this campaign. The current institutional campaign seems to have a very modest impact. There is a need to develop studies to better understand the reason for the suboptimal vaccination in order to conduct targeted and effective intervention programs." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Discussion and conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLas cifras de adherencia a la vacunación antigripal de los profesionales sanitarios en España no son bien conocidas. Para la campaña 2017/18, el Ministerio de Sanidad estableció un objetivo mínimo del 40%. La adherencia de los trabajadores de nuestro hospital no se ha medido en años anteriores. Durante la temporada 2017/2018 fortalecimos el seguimiento de la campaña de vacunación. MétodosElaboramos un registro de vacunación incluyendo la unidad de procedencia y la categoría profesional. Realizamos un análisis descriptivo y bivariante. Comprobamos si la incidencia de gripe en el área y el número de pacientes con gripe aislados en el hospital influyeron en la vacunación. Se realizaron actividades de promoción de la campaña. ResultadosLa campaña tuvo lugar entre las semanas 42/2017 y 09/2018. Un total de 895/4.401 profesionales fueron vacunados (20,3%). El 9% de las unidades (4/44) excedió el 40% de la vacunación. El mayor número de vacunaciones ocurrió la semana 44/2017, antes de la ola principal de la epidemia. Se encontró una relación estadísticamente significativa entre vacunación y la unidad de procedencia y categoría profesional. Las estrategias de comunicación no tuvieron efecto. Discusión y conclusiónNuestro registro hizo posible un análisis de la situación de vacunación de profesionales sanitarios en nuestro hospital. La adherencia ha sido subóptima en la temporada analizada. La campaña institucional actual parece tener un impacto muy modesto. Es necesario desarrollar estudios para comprender mejor el motivo de la vacunación subóptima a fin de llevar a cabo programas de intervención más efectivos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Discusión y conclusión" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1664 "Ancho" => 2538 "Tamanyo" => 257582 ] ] "descripcion" => array:1 [ "en" => "Influenza incidence in the hospital's catchment area and distribution of vaccinated HCW and influenza isolated patients per week. Influenza season 2017, 2018. 1Email sent to heads of units. 2Publication of the banner on the hospital's website. 3Oral reminder in the daily meetings between the heads of units and the hospital management." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "X-square=15.695, p<0.01." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Medical unit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Medical-surgical unit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Diagnostic unit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">General unit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccinated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">518 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">262 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">895 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2326 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1534 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">433 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">108 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4401 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccine uptake \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2333488.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Vaccine uptake by working unit. Influenza vaccination campaign. University reference hospital, season 2017/18." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "X-square=106.44, p<0.001." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Administration staff \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nursing assistants \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hospital attendant \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Nurses \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Physicians \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Medical residents \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other health technicians \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccinated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">141 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">281 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">262 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">72 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">895 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">138 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">995 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">351 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1512 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">821 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">286 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">298 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4401 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccine uptake \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20.3% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2333487.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Vaccine uptake by professional profile. 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Original article

Suboptimal influenza vaccine uptake among healthcare workers in a regional reference hospital in Spain, 2017–2018. Need for new approaches

Nivel subóptimo de adherencia a vacunación antigripal entre los profesionales sanitarios en un hospital regional de referencia en España, 2017–2018. Necesidad de nuevos enfoques

R. Ruiz-Monteroa,b, R. Ortiz-González Sernaa,b, B.R. Guzmán-Herradora,b,

Corresponding author

berguzherr@gmail.com

Corresponding author.

, J.L. Barranco Quintanaa,b, F.J. Gavilán Leóna,b, I. Salcedo Leala,b, R. Torcello Gaspara,b, M.J. Romero Muñoza,b, C. Díaz Molinaa,b

a Unidad de Gestión Clínica de Medicina Preventiva y Salud Pública, Hospital Universitario Reina Sofía, Córdoba, Spain

b Maimonides Institute for Research in Biomedicine of Cordoba (IMIBIC), Reina Sofia University Hospital, University of Cordoba, Spain

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including HCWs&#46; However&#44; the suboptimal registration or lack of standardization of available vaccination registries at the healthcare facility level makes hard to get a complete national picture&#46; In any case&#44; the vaccination coverage in HCWs in Spain is estimated to be around 15&#8211;25&#37;&#44; far from targets recommended by the WHO and the EU&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> The Inter-territorial Board of the National Health System set a vaccination coverage of 40&#37; in HCWs<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> as the goal for the 2017&#8211;2018 season&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">HCW&#39;s influenza vaccine coverage at our hospital has not been monitored in a systematic way in previous seasons&#46; We developed a vaccination registry during the 2017&#47;18 vaccination campaign to better follow up the vaccine uptake during the season&#44; to have a starting point for measuring trends in future seasons and identify factors that could influence vaccine uptake&#46; Communication activities were planned and conducted to promote de campaign&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Influenza vaccination campaign at our hospital&#46; Vaccine registration and communication strategies</span><p id="par0020" class="elsevierStylePara elsevierViewall">During the 2017&#47;18 season&#44; the Unit of Preventive Medicine and Public Health &#40;UPMPH&#41; was responsible for planning and conducting the influenza vaccination campaign targeting HCWs in our hospital&#46; Our regional university hospital has a catchment area of more than 1&#44;100&#44;000 people&#46; It has 1100 beds and around 4400 HCWs&#46; Shortly before the official start of the influenza vaccination campaign the UPMPH received the vaccines from the Hospital Pharmacy Unit&#46; During the first few weeks of the campaign&#44; a two-hour consultation &#40;08&#58; 30&#8211;10&#58;30 am&#41; with one nurse was set up for vaccination of HCWs&#46; In addition&#44; the vaccine was always offered to any HCW who asked for it during working hours&#44; even outside of those two hours range&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Each HCW being vaccinated at our unit was asked for their professional profile &#40;administration staff&#44; hospital attendant&#44; nursing assistant&#44; nurse&#44; physician&#44; physician under training&#47;medical resident&#44; and other health technician&#41; and working unit &#40;44 units&#41;&#46; The information was collected in an aggregated way in a paper sheet during the consultation and transferred to an electronic sheet at the end of each day&#46; In addition&#44; each vaccination was registered individually&#44; with the personal ID of each worker&#44; and vaccine batch in &#8220;<span class="elsevierStyleItalic">Diraya</span><span class="elsevierStyleItalic">Vacunas</span>&#8221;&#44; the Vaccine registry of the Regional Ministry of Health&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted activities to promote the vaccination campaign&#58; several days before the official start we placed an informative sign at the UPMPH door announcing the campaign&#46; On week 45&#47;2017&#44; three weeks after the campaign had started&#44; we circulated an email with a preliminary uptake analysis to all heads of unit asking them to encourage their staff to get vaccinated&#46; During week 46&#47;2017&#44; we posted a banner at the hospital&#39;s official website encouraging vaccination with a photograph of HCWs&#46; During week 51&#47;2017 several oral reminders were made during the daily meetings between head of units and the hospital management&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Data analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">We conducted a descriptive analysis by week&#44; HCW profile and working unit&#46; The Human Resources Unit provided us with the total number of HCWS by working unit and professional profile in the hospital&#44; to be able to calculate proportions&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In addition&#44; we performed two Chi-square tests to determine whether the professional profile and working unit influenced vaccine uptake&#46; The working unit was grouped in four categories&#44; based on the Portfolio document of Specialized Services of the Regional Health Service&#58; &#40;1&#41; <span class="elsevierStyleItalic">Medical</span>&#58; Allergology&#44; Gastroenterology&#44; Cardiology&#44; Endocrinology&#44; Hematology&#44; Internal Medicine&#44; Infectious diseases&#44; Intensive Medicine&#44; Nuclear Medicine&#44; Nephrology&#44; Pneumology&#44; Neurology&#44; Medical Oncology&#44; Radiation Oncology&#44; Pediatrics&#44; Rehabilitation&#44; Rheumatology&#44; Mental Health&#44; Emergency and Palliative Care&#46; &#40;2&#41; <span class="elsevierStyleItalic">Medical-Surgical</span>&#58; Anesthesia&#44; Cardiovascular Surgery&#44; General Surgery&#44; Maxillofacial Surgery&#44; Pediatric Surgery&#44; Plastic Surgery&#44; Thoracic Surgery&#44; Dermatology&#44; Neurosurgery&#44; Obstetrics and Gynecology&#44; Ophthalmology&#44; Otolaryngology&#44; Traumatology and Orthopedics and Urology&#46; &#40;3&#41; <span class="elsevierStyleItalic">Diagnostics</span>&#58; Clinical Analysis&#44; Pathology&#44; Immunology&#44; Microbiology&#44; Radiodiagnosis and Clinical Neurophysiology&#41;&#46; &#40;4&#41; <span class="elsevierStyleItalic">General</span>&#58; Pharmacy&#44; Physics and Radiological Protection&#44; Preventive Medicine and Public Health and Occupational Medicine&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We checked whether changes in influenza incidence in the area influenced the perception of risk among HCWs&#44; increasing vaccine uptake&#46; To explore this&#44; we used weekly influenza incidence data in our province&#44; published weekly by the Sentinel Influenza Surveillance System of the Regional Ministry of Health &#40;<a href="https://www.juntadeandalucia.es/organismos/saludyfamilias/areas/salud-vida/vigilancia/paginas/vigilancia-transmisibles.html">https&#58;&#47;&#47;www&#46;juntadeandalucia&#46;es&#47;organismos&#47;saludyfamilias&#47;areas&#47;salud-vida&#47;vigilancia&#47;paginas&#47;vigilancia-transmisibles&#46;html</a>&#41;&#46; As a proxy for the burden of influenza admissions in our hospital we used the cumulative number of patients admitted under droplet precautions due to influenza by week&#46; The analysis was conducted with Microsoft Excel and R studio&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The 2017&#8211;2018 vaccination campaign officially began on Monday&#44; October 23&#44; 2017 &#40;week 42&#47;2017&#41;&#46; The end of the campaign was marked by the decline of the epidemic curve under the epidemic threshold which occurred on Saturday&#44; March 3&#44; 2018 &#40;week 09&#47;2018&#41;&#46; The vaccine was available at UPMPH during the entire period&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">A total of 895&#47;4401 HCWs were vaccinated &#40;20&#46;3&#37;&#41; at our Unit&#46; The number of vaccines that were administered peaked on week 44&#47;2017 &#40;226 doses administered&#41;&#44; followed by a downward trend until the beginning of January&#44; except for two small vaccination peaks on weeks 48 and 51&#47;2017 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Only 9&#37; of the units &#40;4&#47;44&#41; exceeded 40&#37; vaccination uptake&#44; fulfilling the objective of the National and Regional Ministry of Health&#46; Thirty four percent of the units &#40;15&#47;44&#41; reached between 20&#37; and 39&#37; uptake and more than half &#40;57&#37;&#59; 25&#47;44&#41; had less than 20&#37;&#46; The vaccine coverage was 22&#46;2&#37; in medical units&#44; 21&#46;2&#37; in diagnostic and general units and 17&#37; in medical-surgical units &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; By professional profile&#44; physicians &#40;32&#37;&#41;&#44; and medical residents &#40;25&#37;&#41; had the highest percentages &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; None of the professional profiles reached the goal of the Regional&#47;National Ministry of Health&#46; A statistically significant relationship was found between vaccine uptake and grouped working unit &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41; and professional profile &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The largest number of vaccinations occurred at the beginning of the campaign &#40;week 44&#47;2017&#41;&#44; much earlier than the main peak of the influenza season in our province&#44; which occurred on week 51&#47;2017 &#40;467&#46;5 cases per 100&#44;000 inhabitants&#41;&#46; The first patient isolated under droplet precautions with influenza was admitted at the hospital on week 48&#47;2017&#46; Since then&#44; the number of isolated patients under droplet precautions with influenza had an increasing trend until week 02&#47;2018 &#40;with 105 isolated patient-days&#41; and then slowly decreased until week 16&#47;2018 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The first and the main peak of the epidemic was reflected in the hospital by a large increase in patients isolated under droplet precautions and a slight increase in vaccinations in HCWs &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The email sent to heads of units &#40;1&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and the inclusion of the banner on the hospital&#39;s website &#40;2&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; did not influence vaccinations&#46; There was a slight increase in vaccination uptake coinciding with the oral reminder in the daily meetings between the heads of units and the hospital management &#40;3&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The design of a vaccination registry made feasible a deeper follow-up and analysis of the influenza vaccination campaign among HCWs at our hospital during the 2017&#8211;2018 season and will be very useful to measure trends during the next years&#46; The implementation of a similar type of registry&#44; simple&#44; timely and with high quality denominators&#44; in other hospitals could help to obtain a clearer national picture of vaccine uptake among HCWs&#46; Our results indicate that vaccine coverage of HCWs in our hospital this season has been suboptimal&#44; with a global vaccination uptake of 20&#46;3&#37;&#46; This is far from the 40&#37; marked by the Regional&#47;National Ministry of Health&#46; However&#44; it is within the average vaccination adherence estimated in Spain &#40;15&#8211;25&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> Both lower and higher percentages have been described by other studies in Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">10&#8211;12</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">We found a statistically significant relationship between vaccine uptake and the professional profile or the working unit category&#46; We observed that a clear majority of HCWs get vaccinated at the beginning of the campaign&#46; The period in which the first and the main influenza peak occurred led to a slight increase in the vaccination of HCWs&#44; which we believe could be due to an increased perception of risk&#46; The number of patients isolated under droplet precautions with influenza&#44; and the incidence of influenza was much higher after week 51&#47;2017&#44; but this did not trigger a new peak in vaccinations&#46; This seems to indicate that the majority of HCWS who get vaccinated do so out of self-awareness at the beginning of the campaign and not because of risk perception&#46; The communication strategies conducted during the campaign had no or very little effect in vaccinations&#46; More intense communication activities&#44; such us videos including clear messages displayed at the hospital screens and social media&#44; or additional vaccination points in the different hospital buildings&#44; as suggested in other studies&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> could have an impact and could be considered as an improvement and evaluated for future campaigns&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">We acknowledge some limitations in the interpretation of our results&#46; First&#44; we could somehow be underestimating the vaccine uptake since a limited number of HCWs could have chosen to be vaccinated at their primary care center and would have not been registered in our Unit&#46; We believe this number to be rather low as it is easier for HCWs to be vaccinated during working hours at the hospital than asking for an appointment in their primary health care center&#46; We did not collect information on age or years of working experience&#44; which could have also influenced vaccination&#46; It would have been interesting to know which proportion of HCWs belong to an additional vulnerable group &#40;e&#46;g&#46; chronic disease or close contact with a person with chronic pathology&#41; and evaluate the reason that had more weight for these HCWs to ask for the vaccine&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">It is difficult to compare our estimates with other countries since not all monitor influenza vaccine uptake in the different risk groups&#44; making difficult to establish trends in each country or region&#46; With the aim of exploring this issue&#44; the European Center for Disease Prevention and Control &#40;ECDC&#41;&#44; regularly publishes a technical report with a description of influenza vaccination recommendations and uptake in the EU Member States&#46; The last published report has been that of the 2015&#8211;16 and 2015&#8211;16 flu seasons&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> The report presents the results of the analysis of an electronic questionnaire that was distributed to the national focal points for influenza surveillance in the different Member States&#46; In 29 of the 30 countries that responded&#44; influenza vaccination was recommended in HCWs&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> The coverage among HCWs was known in 12 Member States and ranged from 15&#46;6&#37; to 63&#46;2&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> The report shows a wide variability within the continent&#44; although it does not include information on the possible reasons that may influence this greater or lesser success of the vaccination campaigns&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">ECDC has recently warned about the low acceptance of influenza vaccine in Europe and encourages Member States to analyze the reasons why people belonging to risk groups&#44; such as HCWs&#44; decline vaccination&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">14</span></a> Very few countries have specific data that explain the reasons for the low and variable HCWs&#8217; adherence to vaccination&#44; as well as attitudes&#44; knowledge and practices toward the vaccine&#46; Cross-sectional studies carried out in Italy&#44; Spain and Germany estimated that the misconceptions related to the influenza vaccine in health HCWs are related to low risk perception&#44; skepticism on the effectiveness and safety of the vaccine and general disinformation&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">15&#8211;20</span></a> However&#44; there is little information on whether the reasons for non-vaccination and the level of knowledge and awareness vary according to the level of healthcare provided and if there are significant differences that require different intervention programs adapted to different professional profiles&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">ECDC and the studies mentioned above recommend enhancing vaccination communication strategies and education by implementing innovative information campaigns to eliminate barriers to vaccine acceptance&#46; However&#44; there are very few studies that assess the effectiveness of such interventions&#44; and whether such effectiveness varies by context&#46; A review published in 2013<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> analyzed interventions that had been used to increase adherence to influenza vaccination in HCWs&#46; The review concluded that a successful intervention should have different comprehensive intervention packages&#44; well supported by the hospital management&#44; with dedicated staff and communication and promotion strategies with messages directed and adapted to the different professional profiles&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">Low adherence to influenza vaccination by HCWs is an international public health problem&#46; In our hospital&#44; as in Spain and other European Member States&#44; the current institutional campaign&#44; seem to have low effectiveness and a very modest impact&#44; with vaccination levels far from those recommended by the WHO&#46; Therefore&#44; we consider the need to develop studies to better understand the reason for the suboptimal vaccination&#46; Only then&#44; intervention programs with innovative communication&#44; education&#44; training and information exchange strategies targeting different professional profiles could be planned conducted and evaluated&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Author contributions</span><p id="par0105" class="elsevierStylePara elsevierViewall">All authors have been involved in the design&#44; daily development and management of the vaccination campaign and data collection&#46; CDM and MJRM have coordinated the vaccination campaign&#46; RRM and ROGS have conducted the analysis and interpretation of the results&#46; BGH&#44; RRM&#44; ROGS have drafted the manuscript&#46; BGH has coordinated the manuscript drafting and interpretation of results&#46; All authors have provided comments to the initial draft approved the last version for publication&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">This research has not received specific support from public sector agencies&#44; business sector or non-profit entities&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">All authors were health workers from the Preventive Medicine Unit at the Reina Sofia University Hospital while the study was conducted&#46; The activities described in this study are included within the terms of reference of the Unit&#46; BGH and JBQ have received payment by Sanofi Pasteur for teaching activities&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Spanish figures on Influenza vaccine uptake among health care workers &#40;HCWs&#41; are not well known&#46; For the 2017&#47;18 campaign&#44; the Spanish Ministry of Health established a minimum goal of 40&#37;&#46; HCWs&#8217; uptake at our hospital has not been measured in previous years&#46; During the 2017&#47;2018 season we enhanced the follow up of the vaccination campaign in our hospital&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We set up a vaccination registry including working unit and professional profile&#46; We conducted a descriptive and bivariate analysis&#46; We checked whether influenza incidence in the area and the number of influenza patients admitted with influenza in the hospital influenced vaccination&#46; Communication activities were conducted to promote the campaign&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The campaign lasted from week 42&#47;2017 to 09&#47;2018&#46; A total of 895&#47;4401 HCWs were vaccinated &#40;20&#46;3&#37;&#41;&#46; Only 9&#37; of the units &#40;4&#47;44&#41; exceeded 40&#37; vaccination uptake&#46; The number of administered vaccines peaked on week 44&#47;2017&#44; before the main epidemics wave started&#46; A statistically significant relationship was found between vaccine uptake and working unit and professional profile&#46; Communication strategies during the campaign had no effect in vaccine uptake&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our registry made feasible a situation analysis of vaccine uptake among HCWs at our hospital and will be useful to measure future trends&#46; HCWs vaccine uptake has been suboptimal during this campaign&#46; The current institutional campaign seems to have a very modest impact&#46; There is a need to develop studies to better understand the reason for the suboptimal vaccination in order to conduct targeted and effective intervention programs&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las cifras de adherencia a la vacunaci&#243;n antigripal de los profesionales sanitarios en Espa&#241;a no son bien conocidas&#46; Para la campa&#241;a 2017&#47;18&#44; el Ministerio de Sanidad estableci&#243; un objetivo m&#237;nimo del 40&#37;&#46; La adherencia de los trabajadores de nuestro hospital no se ha medido en a&#241;os anteriores&#46; Durante la temporada 2017&#47;2018 fortalecimos el seguimiento de la campa&#241;a de vacunaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Elaboramos un registro de vacunaci&#243;n incluyendo la unidad de procedencia y la categor&#237;a profesional&#46; Realizamos un an&#225;lisis descriptivo y bivariante&#46; Comprobamos si la incidencia de gripe en el &#225;rea y el n&#250;mero de pacientes con gripe aislados en el hospital influyeron en la vacunaci&#243;n&#46; Se realizaron actividades de promoci&#243;n de la campa&#241;a&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La campa&#241;a tuvo lugar entre las semanas 42&#47;2017 y 09&#47;2018&#46; Un total de 895&#47;4&#46;401 profesionales fueron vacunados &#40;20&#44;3&#37;&#41;&#46; El 9&#37; de las unidades &#40;4&#47;44&#41; excedi&#243; el 40&#37; de la vacunaci&#243;n&#46; El mayor n&#250;mero de vacunaciones ocurri&#243; la semana 44&#47;2017&#44; antes de la ola principal de la epidemia&#46; Se encontr&#243; una relaci&#243;n estad&#237;sticamente significativa entre vacunaci&#243;n y la unidad de procedencia y categor&#237;a profesional&#46; Las estrategias de comunicaci&#243;n no tuvieron efecto&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusi&#243;n y conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Nuestro registro hizo posible un an&#225;lisis de la situaci&#243;n de vacunaci&#243;n de profesionales sanitarios en nuestro hospital&#46; La adherencia ha sido sub&#243;ptima en la temporada analizada&#46; La campa&#241;a institucional actual parece tener un impacto muy modesto&#46; Es necesario desarrollar estudios para comprender mejor el motivo de la vacunaci&#243;n sub&#243;ptima a fin de llevar a cabo programas de intervenci&#243;n m&#225;s efectivos&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
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            "titulo" => "M&#233;todos"
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          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Discusi&#243;n y conclusi&#243;n"
          ]
        ]
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    "multimedia" => array:3 [
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        "mostrarDisplay" => false
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Influenza incidence in the hospital&#39;s catchment area and distribution of vaccinated HCW and influenza isolated patients per week&#46; Influenza season 2017&#44; 2018&#46;</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">1</span>Email sent to heads of units&#46;</p> <p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">2</span>Publication of the banner on the hospital&#39;s website&#46;</p> <p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">3</span>Oral reminder in the daily meetings between the heads of units and the hospital management&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Medical unit&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">518&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">262&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">895&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2326&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1534&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">433&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">108&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4401&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vaccine uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">17&#46;1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21&#46;2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">21&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">20&#46;3&#37;&nbsp;\t\t\t\t\t\t\n
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Administration staff&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Vaccinated&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">141&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">281&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">262&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">72&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">895&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">138&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">995&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">351&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1512&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">821&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">286&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">298&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 15769887
Original language: English

DOI:10.1016/j.vacun.2019.12.001

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Year/Month	Html	Pdf	Total

2024 October	5	3	8
2024 September	5	5	10
2024 August	7	5	12
2024 July	10	9	19
2024 June	9	8	17
2024 May	9	8	17
2024 April	7	7	14
2024 March	8	7	15
2024 February	8	4	12
2024 January	6	0	6
2023 December	8	0	8
2023 November	10	0	10
2023 October	25	0	25
2023 September	10	0	10
2023 August	13	0	13
2023 July	13	2	15
2023 June	3	2	5
2022 November	3	3	6
2022 October	5	5	10
2022 September	4	5	9
2021 March	1	0	1
2020 July	1	0	1

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