Flu Shot Protocol May Help Efforts to Improve COVID-19 Vaccination


An individualized model that provides vaccine-hesitant patients resources without compromising autonomy could aid efforts to limit the pandemic with new vaccines.

flu shot

A quality improvement plan aimed at improving influenza (flu) vaccination rates may serve to benefit clinicians and caregivers now tasked with assuring community buy-in to coronavirus 2019 (COVID-19) vaccines.

An assessment of a medical committee-guided effort to standardize practices that would increase flu vaccination rates in an urban allergy outpatient clinic showed potential for broader application. And with fewer strategies in place for already available COVID-19 vaccines, the international team of investigators believe similar tactics could carry over.

Led by Justin Chin, DO, of the Lake Erie College of Osteopathic Medicine, investigators sought out the creation of a quality improvement medical committee of clinicians to address multiple years of below-average influenza vaccination rates—as per <14% of eligible encounters—at a hospital-affiliated outpatient allergy and immunology practice in New York.

The panel comprised lists of challenges at the forefront of the practice’s inability to better vaccinate—including limited on-hand patient vaccine records and a reluctance to vaccinate in conjunction with allergy care, at risk of potential adverse events.

They also compiled patient perspectives, including a growing narrative of vaccine hesitancy in the public and harmful media portrayal of vaccination effects. Among considered interventions to combat vaccine stigma included provider-level education, the implementation of support staffs informed on evidence-based vaccine data, and vaccine counseling.

Prior to the 2019-20 flu season, providers established a vaccination goal of 71%, set protocol for vaccine counseling and documentation, and crated a workflow that required staff asking patients their flu vaccination status during intake. The allergy care team also discussed providing reviewed literature on vaccine hesitancy and common concerns regarding the annual shot for their specific patient population.

Eligible patients for their program were 18-80 years old, from any of 4 providers’ records. Every patient had at least 1 visit with a participating provider between October-March of that flu season, and had no contraindications to receiving the flu shot.

Chin and colleagues’ patient population included 984 participants. In the 2 flu seasons prior to 2019-20, flu vaccination rates among the 4 providers were 9.25%, then 13.60%. Under the committee-guided protocols, flu vaccination rates spiked to 91.34% in 2019-20.

As the investigators noted, direct patient education is frequently the resolve for healthcare providers who must guide an uncertain patient toward absolute beneficial care while respecting their autonomy.

“Studies have shown, however, that direct education may increase vaccination reluctance as patients utilize refusal as a psychological defense reaction to perceived challenges of their beliefs and knowledge,” they wrote. “Several strategies have been implemented in vaccination efforts over the past decades with variable levels of patient engagement and success.”

Motivational interview, by way of allowing patients to express their concerns or questions surrounding a form of care such as vaccination, may alleviate such issues while remaining again respectful to a patient’s final decision.

“An additional benefit of motivational interviewing is that it further enhances the patient-doctor relationship, as poor rapport/connection has been demonstrated to negatively influence vaccination,” investigators wrote. “It is important for providers to recognize that vaccination beliefs are not static and can change from visit to visit.”

As a pair of COVID-19 vaccines have already reached the emergency authorization state and have been rolled out in the millions thus far, Chin and colleagues stressed the need for multi-level, practice-centered strategies that actively address combat vaccine hesitancy.

A model including protocols for up-front vaccine history inquiry, as well as available resources addressing specific patient concerns, may be replicable in practices as more COVID-19 vaccines near regulatory approval.

“The importance of patient education and commitment in stopping the spread of the COVID-19 virus in their family and community can be leveraged with up to date and unbiased information in order to allow them to voice concerns and improve provider-patient trust through transparency,” investigators concluded. “The influenza vaccination quality improvement project presented here can be used as a guideline for future evaluations of COVID-19 vaccination efforts.”

The study, “Influenza Vaccination Quality Improvement as a Model for COVID-19 Prophylaxis,” was published online in Europe PMC.

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