Hostname: page-component-78c5997874-fbnjt Total loading time: 0 Render date: 2024-11-14T04:33:18.226Z Has data issue: false hasContentIssue false
  • English
  • Français

Prevention of Nosocomial Influenza

Published online by Cambridge University Press:  02 January 2015

Karim A. Adal ,
Richard H. Flowers ,
Anne M. Anglim ,
Frederick G. Hayden ,
Maureen G. Titus ,
Betty J. Coyner  and
Barry M. Farr
Karim A. Adal
Affiliation:
University of Virginia Health Sciences Center, Charlottesville, Virginia
Richard H. Flowers
Affiliation:
University of Virginia Health Sciences Center, Charlottesville, Virginia
Anne M. Anglim
Affiliation:
University of Virginia Health Sciences Center, Charlottesville, Virginia
Frederick G. Hayden
Affiliation:
University of Virginia Health Sciences Center, Charlottesville, Virginia
Maureen G. Titus
Affiliation:
University of Virginia Health Sciences Center, Charlottesville, Virginia
Betty J. Coyner
Affiliation:
University of Virginia Health Sciences Center, Charlottesville, Virginia
Barry M. Farr*
Affiliation:
University of Virginia Health Sciences Center, Charlottesville, Virginia
*
University of Virginia Health Sciences Center, Box 473, Charlottesville, VA 22908
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

To study compliance with preventive strategies at a university hospital during an outbreak of nosocomial influenza A during the winter of 1988, and the rates of vaccination of healthcare workers and of nosocomial influenza following changes in vaccine practices after the outbreak.

Design:

Retrospective review of employee health, hospital epidemiology, hospital computing, and clinical microbiology records.

Setting:

A university hospital.

Interventions:

Unvaccinated personnel with exposure within the previous 72 hours to an unisolated case of influenza were offered influenza vaccine and 14 days of amantadine hydrochloride prophylaxis. Personnel with exposure more than 72 hours before evaluation were offered vaccine. A mobile cart was introduced for vaccinating personnel after the 1988 outbreak.

Results:

An outbreak of influenza with 10 nosocomial cases occurred in 1988. Only 4% of exposed employees had been vaccinated previously and 23% of exposed, unvaccinated employees agreed to take vaccine, amantadine, or both. A mobile-cart vaccination program was instituted, and annual vaccination rates steadily increased from 26.3% in 1989 to 1990 to 38% in 1993 to 1994 (P<.0001). The relative frequency of documented cases of influenza in employees with symptoms of influenza decreased significantly during this period (P=.025), but nosocomial influenza rates among patients did not change significantly.

Conclusion:

A mobile-cart influenza vaccination program was associated with a significant increase in compliance among healthcare workers, but a majority still remained unvaccinated. The rate of nosocomial influenza among patients was not reduced by the modest increase in the vaccination rate, but influenza rates remained acceptably low, perhaps due to respiratory isolation of patients and furlough of employees with influenza.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 17 , Issue 10 , October 1996 , pp. 641 - 648
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1996 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Pasteur, L. Address to the Fraternal Association of Former Students of the École Centrale des Arts et Manufactures, Paris, France. March 15, 1884.Google Scholar
2. Hammond, GW, Cheang, M. Absenteeism among hospital staff during an influenza epidemic: implications for immunoprophylaxis. Can Med Assoc J 1984;131:449–452.Google ScholarPubMed
3. Centers for Disease Control and Prevention. Prevention and control of influenza: Part I, vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1993;42(No. RR-6):1–14.Google Scholar
4. Strassburg, MA, Greenland, S, Sorvillo, FJ, Lieb, LE, Habel, LA. Influenza in the elderly: report of an outbreak and a review of vaccine effectiveness reports. Vaccine 1986;4:38–44.CrossRefGoogle Scholar
5. Fedson, DS. Immunizations for health-care workers and patients in hospitals. In: Wenzel, RP, ed. Prevention and Control of Nosocomial Infections. Baltimore, MD: Williams & Wilkins;1993:217–222.Google Scholar
6. Wenzel, RP, Osterman, CA, Hunting, KJ, Gwaltney, JM Jr. Hospital-acquired infections, I: surveillance in a university hospital. Am J Epidemiol 1976;103:251–260.CrossRefGoogle ScholarPubMed
7. Dowdle, WA, Kendal, AP, Noble, GR. Influenza viruses. In: Lennette, E, Schmidt, N, eds. Diagnostic Procedures for Viral, Rickettsial, and Chlamydial Infections. Washington, DC: American Public Health Association, Inc; 1979:592–600.Google Scholar
8. Stokes, CE, Bernstein, JM, Kyger, SA, Hayden, FG. Rapid diagnosis of influenza A and B by 24-h fluorescent focus assays. J Clin Microbiol 1988;26:1263–1266.10.1128/jcm.26.7.1263-1266.1988CrossRefGoogle Scholar
9. Rosner, B. Fundamentals of Biostatistics. 3rd ed. Belmont, CA: Duxbury Press; 1990:357–360.Google Scholar
10. Ghendon, Y. Influenza—its impact and control. World Health Stat Q 1992;45:306–311.Google ScholarPubMed
11. Sprenger, MJW, Mulder, PGH, Beyer, WEP, Van Strik, R, Masurel, N. Impact of influenza on mortality in relation to age and underlying disease, 1967-1989. Int J Epidemiol 1993;22:334–340.CrossRefGoogle ScholarPubMed
12. Sullivan, KM, Monto, AS, Longini, IM Jr. Estimates of the US health impact of influenza. Am J Public Health 1993;83:1712–1716.CrossRefGoogle ScholarPubMed
13. McBean, AM, Babish, JD, Warren, JL. The impact and cost of influenza in the elderly. Arch Intern Med 1993;153:2105–2111.10.1001/archinte.1993.00410180051005CrossRefGoogle ScholarPubMed
14. Coles, FB, Balzano, GJ, Morse, DL. An outbreak of influenza A (H3N2) in a well immunized nursing home population. J Am Geriatr Soc 1992;40:589–592.10.1111/j.1532-5415.1992.tb02108.xCrossRefGoogle Scholar
15. Taylor, JL, Dwyer, DM, Coffman, T, Groves, C, Patel, J, Israel, E. Nursing home outbreak of influenza A (H3N2): evaluation of vaccine efficacy and influenza case definitions. Infect Control Hosp Epidemiol 1992;13:93–97.10.1086/646479CrossRefGoogle ScholarPubMed
16. Bean, B, Rhame, FS, Hughes, RS, Weiler, MD, Peterson, LR, Gerding, DN. Influenza B: hospital activity during a community epidemic. Diagn Microbiol Infect Dis 1983;1:177–183.CrossRefGoogle ScholarPubMed
17. Centers for Disease Control. Suspected nosocomial influenza cases in an intensive care unit. MMWR 1988;37:3–4, 9.Google Scholar
18. Gross, PA, Rodstein, M, LaMontagne, JR, et al. Epidemiology of acute respiratory illness during an influenza outbreak in a nursing home. A prospective study. Arch Intern Med 1988;148:559–561.CrossRefGoogle Scholar
19. Arden, NH, Patriarca, PA, Fasano, MB, et al. The roles of vaccination and amantadine prophylaxis in controlling an outbreak of influenza A (H3N2) in a nursing home. Arch Intern Med 1988;148:865–868.CrossRefGoogle ScholarPubMed
20. Christie, RW, Marquis, LL. Immunization roulette: influenza occurrence in five nursing homes. Am J Infect Control 1985;13:174–177.CrossRefGoogle ScholarPubMed
21. Gross, PA, Quinnan, GV, Rodstein, M, et al. Association of influenza immunization with reduction in mortality in an elderly population. A prospective study. Arch Intern Med 1988;148:562–565.10.1001/archinte.1988.00380030068015CrossRefGoogle Scholar
22. Ikeda, RM, Drabkin, PD, Birkhead, GS. Influenza A outbreaks in nursing homes. J Am Geriatr Soc 1992;40:1288. Letter.10.1111/j.1532-5415.1992.tb03659.xCrossRefGoogle ScholarPubMed
23. Mast, EE, Harmon, MW, Gravenstein, S, et al. Emergence and possible transmission of amantadine-resistant viruses during nursing home outbreaks of influenza A (H3N2). Am J Epidemiol 1991;134:988–997.CrossRefGoogle ScholarPubMed
24. Pachuki, CT, Walsh Pappas, SA, Fuller, GF, Krause, SL, Lentino, JR Schaaff, DM. Influenza A among hospital personnel and patients. Implications for recognition, prevention, and control. Arch Intern Med 1989;149:77–80.CrossRefGoogle Scholar
25. Patriarca, PA, Weber, JA, Parker, RA, et al. Efficacy of influenza vaccine in nursing homes. Reduction in illness and complications during an influenza A (H3N2) epidemic. JAMA 1985;253:1136–1139.CrossRefGoogle ScholarPubMed
26. Patriarca, PA, Weber, JA, Parker, RA, et al. Risk factors for outbreaks of influenza in nursing homes. Am J Epidemiol 1986;124:114–119.CrossRefGoogle ScholarPubMed
27. Sérié, C, Barme, M, Hannoun, C, Thibon, M, Beck, H, Aquino, JP. Effects of vaccination on an influenza epidemic in a geriatric hospital. Dev Biol Stand 1977;39:317–321.Google Scholar
28. Glezen, WP Falcao, O, Cate, TR, Mintz, AA. Nosocomial influenza in a general hospital for indigent patients. Can J Infect Control 1991;6:65–67.Google Scholar
29. Wenzel, RP Deal, EC, Hendley, JO. Hospital-acquired viral respiratory illness on a pediatric ward. Pediatrics 1977;60:367.CrossRefGoogle ScholarPubMed
30. Serwint, JR, Miller, RM. Why diagnose influenza infections in hospitalized pediatric patients? Pediatr Infect Dis J 1993;12:200–204.CrossRefGoogle ScholarPubMed
31. Serwint, JR, Miller, RM, Korsch, BM. Influenza type A and B infections in hospitalized pediatric patients: who should be immunized? Am J Dis Child 1991;145:623–626.CrossRefGoogle Scholar
32. Gross, PA, Hermogenes, AW, Sacks, HS, Lau, J, Levandowski, RA. The efficacy of the influenza vaccine in elderly persons: a meta-analysis and review of the literature. Ann Intern Med 1995;123:518–527.CrossRefGoogle Scholar
33. Barker, WH, Mullooly, JP. Influenza vaccination of elderly persons. Reduction in pneumonia and influenza hospitalizations and deaths. JAMA 1980;244:2547–2549.10.1001/jama.1980.03310220045026CrossRefGoogle ScholarPubMed
34. Foster, DA, Talsma, A, Furumoto-Dawson, A, et al. Influenza vaccine effectiveness in preventing hospitalization for pneumonia in the elderly. Am J Epidemiol 1992;136:296–307.CrossRefGoogle ScholarPubMed
35. Fedson, DS, Wajda, A, Nicol, JP, Hammond, GW, Kaiser, DL, Roos, LL. Clinical effectiveness of influenza vaccination in Manitoba. JAMA 1993;270:1956–1961.10.1001/jama.1993.03510160074032CrossRefGoogle ScholarPubMed
36. Govaert, TME, Thijs, CTMCN, Masurel, N, Sprenger, MJW, Dinant, GJ, Knottnerus, JA. The efficacy of influenza vaccination in elderly individuals: a randomized double-blind placebo-controlled trial. JAMA 1994;272:1661–1665.CrossRefGoogle ScholarPubMed
37. Balkovic, ES, Goodman, RA, Rose, FB, Borel, CO. Nosocomial influenza A (H1N1) infection. Am J Med Technol 1980;46: 318–320.Google ScholarPubMed
38. Weingarten, S, Friedlander, M, Rascon, D, Ault, M, Morgan, M, Meyer, RD. Influenza surveillance in an acute-care hospital. Arch Intern Med 1988;148:113–116.CrossRefGoogle Scholar
39. Berlinberg, CD, Weingarten, SR, Bolton, LB, Waterman, SH. Occupational exposure to influenza-introduction of an index case to a hospital. Infect Control Hosp Epidemiol 1989;10:70–73.Google ScholarPubMed
40. Fralick, RA. Absenteeism among hospital staff during influenza epidemic. Can Med Assoc J 1985;133:641–642.Google ScholarPubMed
41. Kimball, AM, Foy, HM, Cooney, MK, Allan, ID, Matlock, M, Plorde, JJ. Isolation of respiratory syncytial and influenza viruses from the sputum of patients hospitalized with pneumonia. J Infect Dis 1983;147:181–184.CrossRefGoogle ScholarPubMed
42. Hoffman, PC, Dixon, RE. Control of influenza in the hospital. Ann Intern Med 1977;87:725–728.CrossRefGoogle ScholarPubMed
43. Gravenstein, S, Miller, BA, Drinka, P. Prevention and control of influenza A outbreaks in long-term care facilities. Infect Control Hosp Epidemiol 1992;13:49–54.CrossRefGoogle ScholarPubMed
44. Garner, JS, the Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Guideline for isolation precautions in hospitals. Infect Control Hosp Epidemiol 1996;17:53–80.CrossRefGoogle ScholarPubMed
45. Degelau, J, Somani, SK, Cooper, SL, Guay, DRP, Crossley, KB. Amantadine-resistant influenza A in a nursing facility. Arch Intern Med 1992;152:390–392.CrossRefGoogle Scholar
46. Jacobs, DS, Langsford, WA, White, GE. Herd immunity following subunit influenza vaccine administration. Med J Aust 1972;2:67–70.Google Scholar
47. Fedson, DS. Influenza prevention and control. Past practices and future prospects. Am J Med 1987;82(suppl 6A):42–47.CrossRefGoogle ScholarPubMed
48. Weingarten, S, Riedinger, M, Bolton, LB, Miles, P, Ault, M. Barriers to influenza vaccine acceptance. A survey of physicians and nurses. Am J Infect Control 1989;17:202–207.CrossRefGoogle ScholarPubMed
49. Pachuki, CT, Lentino, JR, Jackson, GG. Attitudes and behavior of health care personnel regarding the use and efficacy of influenza vaccine. J Infect Dis 1985;151:1170–1171.CrossRefGoogle Scholar
50. Ganguly, R, Russell, DW, Yangco, BV, Chmel, H, Cameron, DJ, Sinnott, J. Influenza vaccination status among health care professionals for prevention of nosocomial infection to hospitalized elderly patients. Serodiagn Immunother Infect Dis 1990;4:309–315.CrossRefGoogle Scholar
51. Russell, DW, Cameron, DJ, Lockey, RF, Behnke, RH, Sinnott, JT, Ganguly, R. Influenza vaccination acceptance among health care professionals. Vaccine 1991;9:691–692.CrossRefGoogle ScholarPubMed
52. Christian, MA. Influenza and hepatitis B vaccine acceptance: a survey of health care workers. Am J Infect Control 1991;19:177–184.CrossRefGoogle ScholarPubMed
53. Watanakunakorn, C, Ellis, G, Gemmel, D. Attitude of healthcare personnel regarding influenza immunization. Infect Control Hosp Epidemiol 1993;14:17–20.CrossRefGoogle ScholarPubMed
54. Nafziger, DA, Herwaldt, LA. Attitudes of internal medicine residents regarding influenza vaccination. Infect Control Hosp Epidemiol 1994;15:32–35.10.1086/646815CrossRefGoogle ScholarPubMed
55. Centers for Disease Control. Prevention and control of influenza. Recommendation of the Immunization Practices Advisory Committee. Ann Intern Med 1984;101:218–222.CrossRefGoogle Scholar
56. Lewy, R. Immunizations among hospital personnel. J Occup Med 1987;29:433–436.Google ScholarPubMed
57. Girasek, DC. Increasing hospital staff compliance with influenza immunization recommendations. Am J Public Health 1990;80:1272–1273.Google ScholarPubMed
58. Ohrt, CK, McKinney, WP. Achieving compliance with influenza immunization of medical house staff and students. A randomized controlled trial. JAMA 1992;267:1377–1380.CrossRefGoogle ScholarPubMed
59. Tominack, RL, Hayden, FG. Rimantadine hydrochloride and amantadine hydrochloride use in influenza A virus infections. Infect Dis Clin North Am 1987;1:459–478.CrossRefGoogle ScholarPubMed
60. Douglas, RG Jr. Prophylaxis and treatment of influenza. N Engl J Med 1990;322:443–450.Google ScholarPubMed
61. Hall, CB, Dolin, R, Gala, CL, et al. Children with influenza A infection: treatment with rimantadine. Pediatrics 1987;80:275–282.CrossRefGoogle ScholarPubMed
62. Hayden, FG, Monto, AS. Oral rimantadine hydrochloride therapy of influenza A virus H3N2 subtype infection in adults. Antimicrob Agents Chemother 1986;29:339–341.10.1128/AAC.29.2.339CrossRefGoogle ScholarPubMed
63. Hayden, FG, Sperber, SJ, Belshe, RB, Clover, RD, Hay, AJ, Pyke, S. Recovery of drug-resistant influenza A virus during therapeutic use of rimantadine. Antimicrob Agents Chemother 1991;35:1741–1747.CrossRefGoogle ScholarPubMed
64. O'Donoghue, JM, Ray, CG, Terry, DW Jr, Beaty, HN. Prevention of nosocomial influenza infection with amantadine. Am J Epidemiol 1973;97:276–282.CrossRefGoogle ScholarPubMed
65. Atkinson, WL, Arden, NH, Patriarca, PA, Leslie, N, Lui, K-J, Gohd, R. Amantadine prophylaxis during an institutional outbreak of type A (H1N1) influenza. Arch Intern Med 1986;146:1751–1756.10.1001/archinte.1986.00360210129019CrossRefGoogle ScholarPubMed
66. Betts, RF, Treanor, JJ, Graman, PS, Bentley, DW, Dolin, R. Antiviral agents to prevent or treat influenza in the elderly. J Respir Dis 1987;8(suppl 11A):556–559.Google Scholar
67. Pettersson, RF, Hellstöm, P-E, Penttinen, K, et al. Evaluation of amantadine in the prophylaxis of influenza A (H1N1) virus infection: a controlled field trial among young adults and high-risk patients. J Infect Dis 1980;142:377–383.CrossRefGoogle ScholarPubMed
68. Dolin, R, Reichman, RC, Madore, HP, Maynard, R, Linton, R, Webber-Jones, J. A controlled trial of amantadine and rimantadine in the prophylaxis of influenza A infection. N Engl J Med 1982;307:580–584.CrossRefGoogle ScholarPubMed
69. Clover, RD, Crawford, SA, Abell, TD, Ramsey, CN Jr, Glezen, WP Couch, RB. Effectiveness of rimantadine prophylaxis of children within families. Am J Dis Child 1986;140:706–709.Google ScholarPubMed
70. Brady, MT, Sears, SD, Pacini, DL, et al. Safety and prophylactic efficacy of low-dose rimantadine in adults during an influenza A epidemic. Antimicrob Agents Chemother 1990;34:1633–1636.CrossRefGoogle ScholarPubMed
71. Galbraith, AW, Oxford, JS, Schild, GC, Watson, GI. Study of 1-amantadine hydrochloride used prophylactically during the Hong Kong influenza epidemic in the family environment. Bull World Health Organ 1969;41:677–682.Google Scholar
72. Galbraith, AW, Oxford, JS, Schild, GC, Watson, GI. Protective effect of 1-adamantanamine hydrochloride on influenza A2 infections in the family environment. A controlled double-blind study. Lancet 1969;2:1026–1028.CrossRefGoogle ScholarPubMed
73. Hayden, FG, Belshe, RB, Clover, RD, Hay, AJ, Oakes, MG, Soo, W. Emergence and apparent transmission of rimantadine-resistant influenza A virus in families. N Engl J Med 1989;321:1696–1702.CrossRefGoogle ScholarPubMed
74. Belshe, RB, Burk, B, Newman, F, Cerruti, RL, Sim, IS. Resistance of influenza A virus to amantadine and rimantadine: results of one decade of surveillance. J Infect Dis 1989;159:430–435.CrossRefGoogle ScholarPubMed
75. Centers for Disease Control. Prevention and control of influenza. Recommendations of the immunization practices advisory committee (ACIP). MMWR 1992;41(No. RR-9):1–17.Google Scholar
76. Belshe, RB, Hall Smith, M, Hall, CB, Betts, R, Hay, AJ. Genetic basis of resistance to rimantadine emerging during treatment to influenza virus infection. J Virol 1988;62:1508–1512.CrossRefGoogle ScholarPubMed
77. Hayden, FG, Couch, RB. Clinical and epidemiological importance of influenza A viruses resistant to amantadine and rimantadine. Rev Med Virol 1992;2:89–96.CrossRefGoogle Scholar
78. Degelau, J, Somani, S, Cooper, SL, Irvine, PW. Occurrence of adverse effects and high amantadine concentrations with influenza prophylaxis in the nursing home. J Am Geriatr Soc 1990;38:428–432.CrossRefGoogle ScholarPubMed
79. Stange, KC, Little, DW, Blatnik, B. Adverse reactions to amantadine prophylaxis of influenza in a retirement home. J Am Geriatr Soc 1991;33:700–705.CrossRefGoogle Scholar
80. Hayden, FG, Gwaltney, JM Jr, Van de Castle, RL, Adams, KF, Giordani, B. Comparative toxicity of amantadine hydrochloride and rimantadine hydrochloride in healthy adults. Antimicrob Agents Chemother 1981;19:226–233.CrossRefGoogle ScholarPubMed
81. Rimantadine for prevention and treatment of influenza. Med Lett Drugs Ther 1993;35:109–110.Google Scholar
82. Ratner, ER, Fedson, DS. Influenza and pneumococcal immunization in medical clinics, 1978-1980. Arch Intern Med 1983;143:2066–2069.CrossRefGoogle ScholarPubMed
83. Setia, U, Serventi, I, Lorenz, P. Factors affecting the use of influenza vaccine in the institutionalized elderly. J Am Geriatr Soc 1985;33:856–858.CrossRefGoogle ScholarPubMed
84. Margolis, KL, Lofgren, RP Korn, JE. Organizational strategies to improve influenza vaccine delivery. A standing order in a general medicine clinic. Arch Intern Med 1988;148:2205–2207.10.1001/archinte.1988.00380100073016CrossRefGoogle Scholar
85. Knoell, KR, Leeds, AL. Influenza vaccination program for elderly outpatients. Am J Hosp Pharm 1991;48:256–259.Google ScholarPubMed
86. Buffington, J, Bell, KM, LaForce, FM, the Genesee Hospital Medical Staff. A target-based model for increasing influenza immunizations in private practice. J Gen Intern Med 1991;6:204–209.CrossRefGoogle ScholarPubMed
87. Nichol, KL, Korn, JE, Margolis, K, Poland, GA, Petzel, RA, Lofgren, RP. Achieving the national health objective for influenza immunization: success of an institution-wide vaccination program. Am J Med 1990;89:156–160.CrossRefGoogle ScholarPubMed
88. Nichol, KL. Improving influenza vaccination rates for high-risk inpatients. Am J Med 1991;91:584–588.CrossRefGoogle ScholarPubMed
89. Nichol, KL. Long-term success with the national health objective for influenza vaccination: an institution-wide model. J Gen Intern Med 1992;7:595–600.CrossRefGoogle ScholarPubMed
90. Crouse, BJ, Nichol, K, Peterson, DC, Grimm, MB. Hospital-based strategies for improving influenza vaccination rates. J Fam Pract 1994;38:258–261.Google ScholarPubMed
91. Chambers, CV, Balaban, DJ, Carlson, BL, Grasberger, DM. The effect of microcomputer-generated reminders on influenza vaccination rates in a university-based family practice center. J Am Board Fam Pract 1991;4:19–26.Google Scholar
92. McDonald, CJ, Hui, SL, Tierney, WM. Effects of computer reminders for influenza vaccination on morbidity during influenza epidemics. MD Comput 1992;9:304–312.Google ScholarPubMed
93. Szilagyi, PG, Rodewald, LE, Savageau, J, Yoos, L, Doane, C. Improving influenza vaccination rates in children with asthma: a test of a computerized reminder system and an analysis of factors predicting vaccination compliance. Pediatrics 1992;90:871–875.CrossRefGoogle Scholar
94. Kemper, KJ, Goldberg, H. Do computer-generated reminder letters improve the rate of influenza immunization in an urban pediatric clinic? Am J Dis Child 1993;147:717–718.Google Scholar
95. Litt, JCB, Lake, PB. Improving influenza vaccine coverage in at-risk groups: good intentions are not enough. Med J Aust 1993;159:542–547.10.5694/j.1326-5377.1993.tb138009.xCrossRefGoogle ScholarPubMed
96. Weingarten, S, Staniloff, H, Ault, M, Miles, P, Bamberger, M, Meyer, RD. Do hospital employees benefit from the influenza vaccine? A placebo-controlled clinical trial. J Gen Intern Med 1988;3:32–37.CrossRefGoogle ScholarPubMed
97. Margolis, KL, Poland, GA, Nichol, KL, et al. Frequency of adverse reactions after influenza vaccination. Am J Med 1990;88:27–30.CrossRefGoogle ScholarPubMed
98. Govaert, TME, Dinant, GJ, Aretz, K, Masurel, N, Sprenger, MJW, Knottnerus, JA. Adverse reactions to influenza vaccine in elderly people: randomised double blind placebo controlled trial. BMJ 1993;307:988–990.CrossRefGoogle ScholarPubMed
99. Aoki, FY, Yassi, A, Cheang, M, et al. Effects of acetaminophen on adverse effects of influenza vaccination in health care workers. Can Med Assoc J 1993;149:1425–1430.Google ScholarPubMed
100. Herwaldt, LA. Greek philosophy, medical ethics, and the influenza vaccine. Infect Control Hosp Epidemiol 1993;14:15–16.CrossRefGoogle ScholarPubMed