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Running Head: Influenza Vaccine 1

Public Education Regarding Immunization and Influenza Vaccination

MacKenzie R. Watson
James Madison University
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The influenza epidemic arrives every year to the U.S. and is most prominent during the months

of October to May. During this time multiple facilities and healthcare providers offer annual

influenza vaccines in order to prevent viral spread and protect our families and loved ones.

Although vaccination against the influenza virus is relatively low in cost and available nearly

everywhere there are still individuals that choose to decline being immunized, leaving

themselves and others at risk. Multiple studies validate and recommend vaccination against the

flu virus is beneficial to avoid infection and/or shorten illness time.

Keywords: Influenza, vaccination, epidemic, immunization, declination of vaccination,

inoculation, flu epidemic, influenza vaccine
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Public Education Regarding Immunization and Influenza Vaccine

Yearly the United States experiences an Influenza epidemic between the months of

October until March. Influenza is epidemic in nature and can yield a high mortality rate due to

secondary pulmonary complications if left untreated, especially if the infected individual is an

older adult or a child under the age of 2 years (Stanhope & Lancaster, 2014). For this reason, the

Centers for Disease Control and Prevention (CDC) recommend yearly vaccinations to protect

from the expected prevalent strain for that term and in most cases these vaccinations can be

obtained for no charge. Vaccination is the most effective method when it comes to prevention

and control of all communicable disease, and when the influenza vaccine is correlated

appropriately with the expected strain the result is 70-90% protection against infection for

individuals that are young and healthy (Stanhope & Lancaster, 2014). Still there are some that

choose not to be inoculated despite the benefit and low cost. Educating the public concerning

vaccination against influenza requires understanding of why individuals are hesitant to be

vaccinated, what risks arise with declination of immunization, and what can be done to inform

the community concerning the need and importance of annual inoculation.

Influenza remains a serious problem affecting the health of the public yearly and leading

to an increase in hospitalizations and associated mortalities. Those with pre-existing co-

morbidities and are older are at even higher risks for influenza and influenza related

complications. The CDC reports that 90% of deaths in the U.S. associated with the flu during

regular flu season occur in ages 65 years and older (Rawipan, et. al., 2015). Due to this, The

World Health Organization (WHO) and the CDC have recommended older adults as one of the

target populations to receive the annual flu vaccine, therefore reducing illness severity by up to

60%, and related deaths by 80% (Rawipan, et. al., 2015). A questionnaire was utilized in a study
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involving 2,693 participants older than 60 years of age, measuring acceptance and willingness to

receive the vaccination after having paid for it. The participants were divided into two groups, a

group that received additional education on the immunization (n=1402), and a control group that

received no additional education (n=1291). The results concluded that 92.8% expressed approval

of the vaccine, but only 43.5% had previously been vaccinated. The study also concluded that a

higher instance of reception was associated with positive attitude regarding the vaccine and a

history of previously being immunized (OR 2.1, 95% Cl 1.5-2.9 and OR 4.1, 95% Cl 2.8-6.1)

(Rawipan, et. al., 2015).

A study aimed at identifying individual barriers to influenza vaccine hesitancy and

declination was performed and included information from thirteen databases and 470 peer

reviewed articles from 2005-2016. Analysis of this information was used to determine obstacles

to vaccination as hesitancy to receive the yearly influenza injection presents a significant threat

to the efforts put forth to reduce the flu epidemic globally (Schmid, 2017). Schimd (2017)

describes vaccine hesitancy as the acceptance of vaccines on a continuum between demand and

no demand ranging from accepting all vaccines to accepting no vaccine. The study also explains

that despite the severity of influenza every year and the low cost and availability of the flu

vaccine that there is still a degree of hesitancy to receive it. This study outlines that barriers to

vaccination can be categorized into a macro-level or a micro-level degree of hesitancy. Macro-

level barriers are prejudiced by what Schmid (2017) describes as complacency, convenience,

and confidence. The implication suggests that the more complacent an individual is the less

threatened they feel by infectious disease and therefore are less likely to follow through with

vaccination, regardless of cost or availability. Inconvenience is also a large factor of vaccine

declination and Schmid (2017) explains that if an individuals attitude is not strongly against or
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in favor of receiving the vaccine then likely they will not attempt to overcome any barriers in

order to obtain it. A strong negative attitude towards vaccination also is a significant obstacle to

confidence in receiving the vaccine. This, along with any misinformation or inaccurate evidence

given to potential receivers of the injection by others, can drastically reduce the volume of

people seeking inoculation for the current flu or projected flu seasons. Micro-level barriers can

be categorized and measured by applying the Theory of Planned Behavior (TPB). This theory is

meant to afford vision and comprehension of why some individuals get vaccinated and some do

not by taking into consideration the individuals attitude, either positive or negative, their

perception of control, and their perception of what is considered normal (Schmid, 2017).

Several barriers were identified throughout the course of the study. Psychological barriers

included an individuals perception of disease risk and their opinion of vaccine safety. Those that

felt they were at low risk for getting influenza were less likely to be vaccinated. There were also

individuals that participated in the study that reported they felt the vaccine had been

insufficiently researched and inadequately tested and therefore reported concerns of safety and

were less likely to be vaccinated. The study also outlined a low degree of pressure from

significant others resulted in lower vaccine uptake. A negative attitude toward vaccination, lack

of trust in authorities (National Health Service and Centers for Disease Control), failure to be

previously immunized, lack of previous experience with sickness related to influenza, and lack

of general knowledge were also identified as psychological barriers in the study. Identified

physical barriers included unhealthy lifestyles (alcohol consumption, smoking, decreased

physical activity, etc.). Contextual barriers comprised of general access to the vaccine due to

political, geographical, or economical demographics as well as lack of establishment in the

healthcare system. One of the largest factors of poor or no vaccine uptake however was living
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alone. Schmid (2017) explains that people who live along generally have limited assistance with

less access to health visits for preventative care and less support from family members than those

that get vaccinated regularly.

Anyone choosing not to be vaccinated against influenza is at risk of contracting the virus

and its associated symptoms. Symptoms range from mild to severe and include runny nose, sore

throat, nausea, vomiting, diarrhea, fever, headache, body aches, chills, cough, loss of appetite

and lethargy (Stanhope & Lancaster, 2014). For individuals under the age of 2 years, older than

65 years, or those with chronic conditions, symptoms may be even worse and pulmonary

complications such as pneumonia can develop. Unrecognized or untreated influenza in these

high risk individuals can cause detrimental outcomes including death.

According to Foppa (2015), there are approximately 25,000 to 35,000 deaths during

influenza season yearly in the United States. A study was performed to estimate the number of

deaths avoided due to influenza vaccination for nine flu seasons beginning in the 2005-2006

season and ending in the 2013-2014 season. The study included four age groups (6 months to 4

years, 5-19 years, 20-64 years, and over 65 years). It was concluded by studies end that the

influenza vaccine averted an estimated 40,127 (95% confidence interval [C1] 25,694 to 59,210)

deaths. (Foppa, et. al., 2015). Foppa (2015) also determined that of the 40,127 avoided deaths,

88.9% (95% Cl 83 to 92.5%) were in the 65 years or older age group.

The influenza vaccine is established as the best preventative measure to avert influenza

and its potential complications and has a reported effectiveness of up to 65% for those 50-64

years of age that have been vaccinated (Arriola, 2015). Arriola (2015) also reported that for those

aged 65 years or older and that had received the flu vaccine that influenza associated medical

visits were reduced by 47-61%. This study was executed using data gathered from the Influenza
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Hospitalization Surveillance Network (FluSurv-NET) for the 2012-2013 seasons. This study

utilized ICU admissions, reports of death, diagnosis of pneumonia, and length of stays in both

hospital and ICUs to measure severity of disease. Included in the analysis were a total of 5,614

adults, age 50 years or older, who were hospitalized with a laboratory confirmed influenza and

met inclusion criteria (Arriola, 2015). Of the 5,614 included, 3,101 (55%) received vaccination

for influenza at least twelve days prior to hospitalization. The 2012-2013 influenza season was

concluded to be moderately severe in comparison to previous flu seasons due to predominant

circulation of Influenza A (H3N2) that year, thus increasing hospitalization for the older adult

population. No variances in severity in relation to vaccination status for the study population was

noted, however the study did find that those included in the study that had been vaccinated were

discharged earlier from the ICU than those who were not (HR, 1.84; 95% Cl, 1.12-3.01) (Arriola,


A commonly cited barrier to vaccination according to Rockwell (2015) is lack of

consistent assessment of vaccination status and a healthcare provider knowledge deficiency

regarding current vaccine recommendation standards. By removing this barrier and providing

more information and education to healthcare providers, vaccination uptake can be monitored

more effectively and updatde when needed. Potential vaccine receivers may be more likely to

immunize if the risks of non-vaccination are discussed with them by their primary care provider.

Inadequate supply of vaccines during peak season is also problematic. This is easily rectified by

increasing supply in accordance to the previous years demands. Many facilities have access to

electronic medical records and immunization registries that ensure accurate tracking of an

individuals vaccination status and vaccination need but fail to utilize them to their full

capability. By using these monitoring systems, healthcare providers will know when to take
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advantage of offering vaccination instead of missing an opportunity while the patient is in their

care. Many facilities have also instituted standing orders for patients that meet vaccination

criteria that sanction nurses, pharmacists, as well as other trained healthcare personnel to

administer vaccines also. Rockwell (2015) illustrates that the best way to intensify community

demand regarding vaccination status is by improving our own knowledge as healthcare providers

in order to educate our patients more accurately and effectively regarding the importance of


Vaccination benefits not only the individual receiving it, but also the community in which

they live as well. Field (2008) explains that widespread vaccination can result in herd

immunity, a phenomenon in which everyone, even the unvaccinated, is protected because the

numbers of susceptible hosts are so minimal that the disease is nearly non-existent. It is when

substantial volumes of individuals choose to decline immunization that herd immunity is lost,

allowing the disease to become reinstated and possibly more severe than before.

Implementations of policies are under critique and discussion in order to promote vaccine use

and development (Field, 2008). Components of this movement include mandates, education for

the public and the clinician, increased research funding to explore vaccine risks, and

compensation for documented vaccine-related injuries (Field, 2008). This benefit also needs to

be addressed with individuals who may move toward vaccination if this information is

recognized. As Rawipan (2015) suggested, the more positive experiences with vaccines, the

more likely people are to be vaccinated regularly in following years.

Influenza is a known, expected, epidemic every year. It is easily avoidable with proper

vaccination to protect against the virus, potential complications related to the virus, and building

medical expenses. By educating the public regarding the spread of influenza, importance of
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vaccination, and the risks of choosing not to be inoculated we can develop a more positive view

of immunization for the community as a whole. By doing this we can facilitate wellness, afford

education, and prevent the spread of illness to others, to ourselves, and our loved ones.
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Arriola, C., Anderson, E., Baumbach, J., Bennet, N., Bohm, N., Hill, M., Lindegren, M., Lung,

K., Meek, J., Mermel, E., Miller, L., Monroe, M., Morin, C., Oni, O., Reingold, A.,

Shaffner, W., Thomas, A., Zanksy, S., Finelli, L., & Chaves, S. (2015). Does influenza

vaccination modify influenza severity? Data on older adults hospitalized with influenza

during the 2012-2013 season in the United States. Journal of Infectious Disease. 212(8).

1200-1208. doi: 10.1093/infdis/jiv200.

Field, R. (2008). Vaccine declinations present new challenges for public health. Pharmacy and

Therapeutics. 33(9). 542-543. Retrieved from

Foppa, I., Cheng, P., Reynolds, S., Shay, D., Carias, C., Bresee, J., Kim, I., Gambhir, M., & Fry,

A. (2015). Deaths averted by influenza vaccination in the U.S. during the seasons

2005/06 through 2013/14. Vaccine. 33(26). 3003-3009.

doi: 10.1016/j.vaccine.2015.02.042

Rawipun, W., Wantanee, W., Kamolnetr, O., Archin, A., Jittima, D., & Punnee, P. (2015).

Health education and factors influencing acceptance of and willingness to pay for

influenza vaccination among older adults. BMC Geriatrics. 15. 136.

doi: 10.1186/s12877-015-0137-6.

Rockwell, P. (2015). What you can do to improve adult immunization rates. The Journal of

Family Practice. 64(10). 625-633. Retrieved from

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Schmid, P., Rauber, D., Betsch, C., Lidolt., D., & Denker, M. (2017). Barriers of influenza

vaccination intention and behavior-A systematic review of influenza vaccine hesitancy,

2005-2016. PLoS One. 12(1). e0170550. doi: 10.1371/journal.pone.0170550.

Stanhope, M., & Lancaster, J. (2014). Foundations of nursing in the community: Community-

oriented practice (4th ed.). St. Louis, Mo.: Mosby/Elsevier.