Low tetanus-diphtheria-acellular pertussis (Tdap) vaccine coverage among healthcare workers in a quaternary university hospital in São Paulo, Brazil: need for continuous surveillance and implementation of active strategies

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w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Low

tetanus-diphtheria-acellular

pertussis

(Tdap)

vaccine

coverage

among

healthcare

workers

in

a

quaternary

university

hospital

in

São

Paulo,

Brazil:

need

for

continuous

surveillance

and

implementation

of

active

strategies

Bruno

Azevedo

Randi

a,b,∗

_,

_Karina

_Takesaki

_Miyaji

a

_,

_Amanda

_Nazareth

_Lara

a

_,

Karim

Yaqub

Ibrahim

a

_,

_Vanessa

_Infante

a,b

_,

_Camila

_Cristina

_Martines

_Rodrigues

b

_,

Marta

Heloísa

Lopes

a,b

_,

_Ana

_Marli

_Christovam

_Sartori

a,b

a_Hospital_das_Clinicas_Divisão_de_Clinica_de_Molestias,_Infecciosas_e_{Parasitarias,}_Centro_de_Referencia_para_{Imunobiologicos}_Especiais, SãoPaulo,SP,Brazil

b_Universidade_de_São_Paulo,_Faculdade_de_Medicina,_Departamento_de_Molestias_Infecciosas_e_{Parasitarias,}_São_Paulo,_SP,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received26February2019

Accepted14June2019

Availableonline26July2019

Keywords: Pertussisvaccine Diphtheria-tetanus-acellular pertussisvaccines Bordetellapertussis Whoppingcough Healthpersonnel

a

b

s

t

r

a

c

t

Introduction:Vaccinationwithtetanus-diphtheria-acellularpertussis(Tdap)hasbeen

rec-ommendedforhealthcareworkers(HCWs)byBrazilianMinistryofHealthsinceNovember

2014.

Objective:TodescribethestrategiesimplementedtoimproveTdapuptake,cumulative

vac-cinecoverageaftereachintervention,variablesassociatedtoTdapvaccination,andreasons

fornon-vaccinationamongHCWsofthemainbuildingofaquaternaryhospitalattachedto

theSaoPauloUniversityMedicalSchool.

Methods:A listofHCWseligibleforpertussisvaccinationwasgenerated.FromAprilto

December 2015,the followinginterventions wereimplemented:noteon internjournal

remindingtheimportanceofpertussisvaccination;emailtotheheadnurses

strengthen-ingvaccinerecommendations;lecturesonpertussisandTdapforphysiciansofObstetrics

andNeonatologyClinics;on-sitevaccinationbymobileteamsattheObstetrics,

Neonatol-ogy,andAnesthesiologyClinics.Vaccinecoveragewasaccessedattheendofeachmonth.

MultivariatePoissonregressionmodelwitharobusterrorvariancewasusedtoevaluate

variablesassociatedwithTdapvaccination.Reasonsfornon-vaccinationwereevaluated

fromJanuarytoMay2017throughphonecallsforHCWswhohadnotreceivedTdap.

∗ _{Corresponding}_author_at:_Dr._Ovídio_Pires_de_Campos_Street,₂₂₅_—_Cerqueira_César,_05403-010,_São_Paulo,_SP,_Brazil.

E-mailaddress:brunorandi@usp.br(B.A.Randi).

https://doi.org/10.1016/j.bjid.2019.06.007

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Results: Thestudyincluded456HCWs.Aftertheinterventions,Tdapcoverageraisedfrom

2.8%to41.2%.Inthemultivariateanalysis,occupation(physician),workingplace

(obstet-ricsoranesthesiology)andinﬂuenzavaccinationin2015wereindependentlyassociatedto

Tdapvaccination.Themainreasonfornon-vaccinationwasunawarenessofTdap

recom-mendations.

Conclusions: TdapuptakeamongHCWswaslowinourhospital.Providingvaccinationat

convenientplaces/timesforHCWseemstobethemostefﬁcientstrategytoincreasevaccine

uptake.

anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Adultvaccination isdifﬁculttoimplement. Mostcountries

havelow vaccinecoverage amongadults.Immunization of

healthcareworkers (HCWs) is challenging, as they usually

showlowperceptionofpersonalriskinvolvedintheir

profes-sionalactivities1,2 _and_hesitate_in_receiving_vaccines._Fear_of

injections,misconceptionsaboutvaccinesefﬁcacyandsafety

and lackoftime are common reasons fornonvaccination

amongHCWs.3

Vaccines recommended for HCWs include inﬂuenza,

hepatitis B, measles-mumps-rubella, varicella,

tetanus-diphtheriaand,insomecountries,adult

tetanus-diphtheria-pertussisacellularvaccine.4

PertussisiscausedbyBordetellapertussis,aGram-negative

bacillustransmittedbyaerosoldroplets.5,6 _It_affects_people

ofall ages, but children agedless than one year are most

affected.7_During_the_last_decades,_pertussis_incidence_raised

globally, in spite of sustained high childhood vaccination

coverage.6 _Waning _immunity_after_vaccination_or _infection,

reduced effectiveness/duration of protection conferred by

acellular pediatric vaccines, increased disease awareness,

improveddiagnosesandsurveillance,andB.pertussis

muta-tionsallowingit toescapeimmunityconferredbyvaccines

havebeenproposedtoexplainpertussisreemergence.5,6 _In

Brazil,pertussisincidenceincreasedfrom0.3/100,000persons

in2010to4/100,000in2014,despitehighcoveragewith

whole-cell vaccines in children.8 _Most _cases _occurred _in _infants

amongwhom theincidencerateincreasedfrom 18/100,000

in2010to152/100,000in2014,andwhoalsohadthehighest

case-fatalityrate(4.6%amonginfantslessthantwomonths

ofage).8

Several Tdap vaccination strategies targeting adults to

reducepertussisamongyounginfantshavebeenproposed,

includingpregnantwomenvaccination,thecocooning

strat-egy (vaccinating all newborns contacts), and vaccination

ofadolescents and adults, including HCWs.5 _HCWs _are _at

increasedrisk of acquiring pertussis through contact with

infectedpatientsandwaningimmunityfollowingchildhood

vaccinationornaturalinfection.9_Therefore,_HCWs_could_be

a source ofpertussis nosocomial outbreaks.10

Recommen-dations on Tdap vaccination for HCWs vary by country.

Somecountries,suchastheUnitedStates,Canada,Australia,

Netherlands,Germany, and UnitedKingdom adopted Tdap

vaccinationforallHCWs,whileothers,suchasAustria,

Fin-landandNorwayintroducedTdaponlyforHCWswhohave

contact with newborns and infants.11 In Brazil, Tdap was

introducedintotheBrazilianNationalImmunizationProgram

(PNI)inNovember2014,targetingpregnantwomenandHCWs

whoareincontactwithnewborns.12

The“InstitutoCentraldoHospitaldasClinicas”(ICHC)is

themainbuildingofaquaternaryteachinghospitalattached

totheMedicalSchoolofSaoPauloUniversity(FMUSP),which

isthelargesthospitalinLatinAmerica.ICHChas850beds.

The “Centro de Referência para Imunobiológicos Especiais

do Hospital das Clínicas” (CRIE-HC) is the immunization

centerofthecomplexandprovidesfreevaccinationas

rec-ommended by the PNI. In March 2015, four months after

Tdap introduction, vaccine coverage among HCWs of the

ICHCforwhomthevaccinewasrecommendedwasverylow

(2.8%).

Thisstudydescribesthestrategiesimplementedin2015to

raiseTdapuptake,thecumulativecoverageaftereachstrategy

andthevariablesassociatedtoTdapvaccinationamongthe

HCWsoftheICHC.

Methods

Adescriptiveobservationalstudywasdesigned.Inclusion

cri-teria:tobeaHCWoftheICHCeligibleforpertussisvaccination

accordingtoPNIrecommendations.AlistofHCWswiththe

recommendationwasprovidedbyICHCdirection.Exclusion

criteria:notregisteredontheCRIE-HCdatasystem(Imuni®),

whichhadthevaccinationhistoryofallserviceusers.Ifthe

HCWwasnotregisteredonImuni®,itimpliesthathe/shehad

neverreceivedavaccineinthatservice.

Toplantheinterventions,weusedourgroupexperience

with seasonal inﬂuenza campaigns13 _and _from _published

papersonTdapcampaigns.14–16

Thefollowinginterventionswereimplementedaimingto

raisevaccinecoverage:

• April2015:anoteonthehospitalinternjournal,

remind-ingthePNIrecommendationsonTdapvaccination,andthe

importanceandsafetyofpertussisvaccinationforHCWs.

The intern journal is a monthly printed magazine, also

availableonline,withnewsandinformsfromthehospital

totheemployees.

• July2015:emailstotheheadnursesofObstetrics,

Neona-tologyandAnesthesiologyClinics,strengtheningtheneed

(3)

• August 2015:alectureonpertussis andTdap

immuniza-tionforphysiciansattheclinicalroundsofObstetricsand

Neonatologydivisions.

• October2015:on-sitevaccinationbymobileteamsat

con-venienttimefortheHCWsattheObstetricsClinic.

• November 2015: on-site vaccination at the Neonatology

Clinic.

• December2015:on-sitevaccinationattheAnesthesiology

Clinic.

Accesstovaccinationwasimprovedthroughon-site

vacci-nationattheprofessional’s workplace,atconvenienttimes

for the HCWs, by mobile teams carrying coolers stocked

withTdapvaccine,aminimum-maximumthermometer,ice

packs,syringes, alcoholhand rub, alcohol wipes,adhesive

bandages, disposal containers for needles, and

documen-tation forms. The on-site vaccination was performed in

two morning periods at the Obstetrics and Neonatology

Clinics and in an evening period at the Anesthesiology

Clinic.

Reasons for non-vaccination were evaluated through

phonecalls(maximumofthreeattemptsforeachHCW)from

JanuarytoMay 2017forthose HCWsthathad notreceived

Tdap.Astandardizedquestionnairewasapplied,askingifthe

HCWknewthevaccine, ifhehadreceivedTdapinanother

serviceand,ifnot,thereasonfornotbeingvaccinated.HCWs

thatdidnothaveaphonenumberregisteredonImuni®could

notbeevaluated.

The following variables were also retrieved from the

Imuni® system: ageatvaccination, sex,occupation

(physi-cianormulti-professionalteam)andinﬂuenzavaccinationin

2015.

Statisticalanalysis

DatafromtheImuni®systemwasusedforthevaccine

cov-erageanalyses.Itwascalculatedbydividingthenumberof

HCWsvaccinatedwithTdapbythetotalnumberofHCWswith

vaccinerecommendationandexpressedaspercentage.

Vac-cinecoveragewasaccessedattheendofeach monthfrom

March2015toApril2016.

Aftercollectingthevariables,adatabankwasdeveloped

inMicrosoftExcelandanalyzedinSTATAversion13.0

(Stata-CorpLP,CollegeStation,Texas,USA).Toevaluatethevariables

associatedwithTdap vaccination, the Chi-squared test(or

Fischerexacttest,whenappropriate)wereused,inthe

uni-variateanalysis,tocalculatetheprevalenceratio andtheir

95%conﬁdenceinterval(95%CI).Thosevariableswithp<0.2

were includedinamultivariate analysis.Multivariate

Pois-sonregressionmodelwitharobusterrorvariancewasused.

Themodeling process wasinitiatedwith the variable with

thelowestp-valueinunivariateanalysis.Thevariableswere

successivelyaddedtothemodel,andonlythosewithp<0.05

stayedintheﬁnalmodel.

Ethicalapproval

This project was approved by the Committee of Ethics in

ResearchoftheHospitaldasClinicas(CAPesqn◦1.662.341).

Results

Studypopulation

Amongthe515HCWswhowereeligibleforTdap

immuniza-tionaccordingtoPNIcriteria,itwasnotpossibletoevaluate

thevaccinestatusof59professionals,becausetheywerenot

registeredontheImuni®systemandtheywerenotfound

dur-ingthestrategiesimplementation.Wecouldnotascertainif

these59professionalsreceivedallvaccines(includingTdap)in

anotherhealthserviceoriftheywerenotvaccinated.

There-fore,theywereexcludedfromtheanalyses.Thus,atotalof

456HCWswereincluded.

Themajority ofthestudy population wasfemale (77%),

under35years-old(50.2%),physicians(50.1%),workedatthe

ObstetricsClinic(42.3%),andhadnotreceivedinﬂuenza

vac-cinationin2015(56.7%).ThirteenHCWswerenutritionistsor

physiotherapists.Astheywerefew,forthepurposeofthe

sta-tisticalanalysis,theywerelumpedtogetherwiththenursing

teaminthemulti-professionalteam.

There were no differences regarding sex (p=0.448), age

(p=0.999),occupation(p=0.383),andplaceofwork(p=0.847)

amongthe456HCWsincludedandthe59excluded

(Supple-mentaryAppendix).

Tdapcoverage

OnJanuary2016,ninemonthsafterimplementingthe

strate-giestoincreasevaccinecoverage,Tdapcoverageraisedfrom

2.8%(13/456)to41.2%(188/456),anincreaseof38.3%.Fig.1

showsthecumulativeTdapvaccinecoverageamongHCWs

attheendofeachmonthandthemomentwhenthe

strate-gieswereimplemented.Spreadinginformationonpertussis

andTdapvaccination(noteininternaljournal,emailstothe

teamsandlecturestothetargetedHCW)raisedvaccine

cov-eragein13.4%(from2.8%to16.2%)whereasprovidingon-site

vaccinationbymobileteamsatconvenienttimesfortheHCW

increasedTdapcoveragein25%(16.2–41.2%).Noother

inter-ventionwasimplementedfromDecember2015toMarch2016,

andthevaccinecoverageremainedstable(41.2%inApril2016).

In the univariate analysis (Table 1), higher Tdap

cov-erage was associated with age (<35 years-old), occupation

(physician),workingplace(obstetricsoranesthesiology),and

inﬂuenza vaccination in2015. Inthe multivariate analysis,

occupation(physician),workingplace(obstetricsor

anesthesi-ology),andinﬂuenzavaccinationin2015wereindependently

associatedtoTdapvaccination(Table2).

Reasonsfornon-vaccination

Amongthe268HCWswhohadnotbeenvaccinated,94did

nothaveaphonenumberregisteredonImuni®system.

There-fore,weattemptedphonecontactwith174HCWswhohadnot

receivedTdap.Foreightofthen,therecordedphonenumber

wasincorrect,and contactwasnotpossibleeither.Only39

(22.4%)ofthe174HCWscouldultimatelybecontacted.Their

characteristicsandreasonsfornon-vaccinationareshownon

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100,0% 90,0% 80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 1 2 3 4 5 6 2.8% 2.8% 3.7% 4.2% Vaccine coverage (%) 4.4% 10.5% 16.2% 22.8% 27.9% 40.6% 41.2% 0,0% March/2015 Apr il/2015

May/2015 June/2015 July/2015 August/2015 September/2015 October/2015 Nove mber/2015 December/2015Ja nuar y/2016

Fig.1–CumulativeTdapvaccinecoverageattheendofeachmonthandinterventionsimplemented.Arrowsrepresentsthe

interventions:(1)publicationnoteonourinternjournal;(2)emailtothenurseteamchiefs;(3)lectureonpertussisfor

physicians;(4)on-sitevaccinationattheObstetricsClinic;(5)on-sitevaccinationattheNeonatologyClinic;(6)on-site

vaccinationattheAnesthesiologyClinic.InstitutoCentraldoHospitaldasClínicas(ICHC),SãoPaulo,Brazil,March2015to

January2016.

Table1–VariablesassociatedwithTdapvaccinationamonghealthcareworkersofaquaternaryuniversityhospitalin univariateanalysis.InstitutoCentral,HospitaldasClinicas—ICHC,SaoPaulo,Brazil.2015–2016.

Variable Total ReceivedTdap PRa _95%CI_(PR) _p-Value

n % Gender 0.345 Male 105 39 37.1 1 Female 351 149 42.5 1.14 0.87–1.51 Age(years) 0.041 ≥35 223 81 36.3 1 <35 229 105 45.9 1.26 1.01–1.58 Occupation 0.003 Multi-professionalteam 219 70 32.0 1 Physician 220 101 45.9 1.44 1.13–1.83 Workingplace <0.001 Neonatology 110 28 25.5 1 Obstetrics 193 107 55.4 2.18 1.54–3.07 Anesthesiology 153 53 34.6 1.36 0.92–2.00 Inﬂuenzavaccinationin2015 <0.001 No 255 82 32.2 1 Yes 195 100 51.3 1.59 1.27–2.00 a _Prevalence_ratio.

Withinthese39HCWs,20(51.2%)reportedknowingTdap

vaccine.Eighteenofthem(90%)werephysiciansandtwo(2%)

belongedto the multi-professional team. Nine HCW (45%)

worksonneonatology,threeonobstetricsclinics,andoneat

anesthesiology.

All nine HCWs that reported having received Tdap

vaccine were physicians. Seven received Tdap on a

pub-lic health service and two at a private health service.

One HCW was under chemotherapy and chose not to

receive the vaccine, even though it is an inactivated

vaccine, without contraindication for immunosuppressed

persons.

Discussion

To ourknowledge, thisis the ﬁrstevaluation ofTdap

cov-erage among HCWs in Brazil. Spontaneous adherence to

Tdap immunizationamongHCWswithdirectcontactwith

infantswas verylowatthis quaternaryuniversityhospital

in Sao Paulo. We initiated our interventions with a

vac-cine coverage of2.8% and achieveda cumulative coverage

of41.2%innine months.Thisincrementalof38.3%in

vac-cinecoveragewasattributedtothestrategiesimplemented.

(5)

Table2–VariablesassociatedwithTdapvaccination amonghealthcareworkersofaquaternaryuniversity hospitalinmultivariatePoissonregressionmodel. InstitutoCentral,HospitaldasClinicas—ICHC,Sao Paulo,Brazil.2015–2016.

Variable PRaja IC95%(PRaj) p-Value

Occupation 0.01 Multi-professionalteam 1 Physician 1.35 1.08–1.69 Workingplace <0.001 Neonatology 1 Obstetrics 2.70 1.74–4.20 Anesthesiology 1.91 1.20–3.04 Inﬂuenzavaccinationin2015 <0.01 No 1 Yes 1.70 1.34–2.15

a _Adjusted_prevalence_ratio.

Table3–Characteristicsof39healthcareworkersofa quaternaryuniversityhospitalwhodidnotreceiveTdap andreasonsfornon-vaccination.InstitutoCentral, HospitaldasClinicas—ICHC,SaoPaulo,Brazil, 2015–2016. Variable n % Gender Male 9 23 Female 30 76.9 Workingplace Neonatology 13 33.3 Obstetrics 8 20.5 Anesthesiology 18 46.1 Occupation Multi-professionalteam 13 33.3 Physician 26 66.7 KnewTdapvaccine 20 51.2

ReceivedTdapinotherservices 9 23 Reasonsfordonotbeingvaccinated 30

DidnotknowTdapwasindicated 27 90

Lackoftime 2 6.67

Chemotherapy 1 3.33

immunization among HCWs helped to increase vaccine uptake,butwebelievevaccinatingthetargetedHCWsattheir workplaceduringworkinghoursbymobileteamswas crit-icaltoincreasevaccinecoveragequickly.However,theﬁnal TdapcoverageamongourHCWsisstilllowandgreaterand continuouseffortsarenecessarytoimpoveit.

Few studies analyzed pertussis immunization coverage speciﬁcally amongHCWs and their results are discrepant. Recently,ourgroupperformedasystematicreviewofTdap coverageamongHCWs.17 _Among_the₂₈_studies_included_in

thereview, onlyﬁvereportedstrategies performedtoraise

vaccinecoverage.14–19

Theﬁrst one was carried out ina pediatric hospital in

Switzerland, where Tdap vaccination program was

imple-mentedduringoneyear.Theprogram,liketheonedeveloped

byus,involvedinformativemessagesandlectures.Differently,

theyscheduledappointmentsforcounselingeachHCW.The

overallpertussisvaccinecoveragewas49%.AmongtheHCWs

thatunderwentcounseling,vaccinecoverageraisedfrom17%

to88%.14

InanotherevaluationofTdapvaccinationinapaediatric

hospitalintheUnitedStates,thecoveragerosefrom58%to

90%after15months.Theauthorssentinformationbyemail

and through the institution intranet, conducted individual

interviews withHCWs and establishedvaccination sitesin

placesofhighﬂowofHCWs.15 _In_the_United_Kingdom,_one

hospitalachievedaTdapcoverage rateof86%and another

achieved95%,threemonthsafterimplementinginformative

posters,oralpresentationsandHCWvaccinationattheirwork

sites.16_In_the_United_States,_two_services_have_achieved_higher

pertussisvaccinecoverageamongHCWswithmandatory

vac-cinationprograms.18,19InPhiladelphia,theGeisingerHealth

System,whichemployed15,267HCWs,hadaninitialTdap

coverage of 9%, which increased to 97.8%, after one year

ofmandatoryHCWsvaccination.19_The_Atlantic_Health

Sys-tem alsointroducedmandatoryHCWs vaccinationin2013,

reachingaﬁnalTdapcoverageof94.9%.18_In_Brazil,_HCW

vac-cinationisnotmandatory,but vaccinationisfreeofcharge

for those who fulﬁll PNI recommendations. Unfortunately,

free availability is not enough to guarantee high vaccine

uptake.

Twocountrieshavenational-baseddataonTdapcoverage

amongHCWs.20,21_The_National_Health_Interview_Surveillance

(NHIS),intheUnitedStates,observedthat45.1%HCWshad

receiveTdapin2015.22_In_France,_among₁₄₃₁_HCW_who

self-reported vaccination, higher coverage (63.9%)was found.21

ThesetwostudiesfoundsigniﬁcantdifferenceonTdap

cover-ageamongdifferentgeographicareaoftheircountries.21,22In

Brazil,dataonvaccinecoverageamongHCWisnotroutinely

available.Thecountryhascontinentaldimensionsandgreat

regionalsocioeconomic,cultural,andhealthsystemstructure

differences.Ourresultsmaynotbeapplytootherregionsof

thecountryortoothertypesofservices,andmorestudiesof

Tdapcoveragearenecessary.

Weobservedthatbeingphysician,workingonobstetrics

oranesthesiologydepartments,andhavingreceivedinﬂuenza

vaccineinthesameyearwereindependentlyassociatedwith

Tdap vaccination. Othersstudies alsoobserved association

ofHCWpertussisimmunizationwithbeingphysician21 _and

inﬂuenzavaccination.9,21_Age_under₄₉_years,9,21_higher

edu-cationlevel, havingbeen hospitalizedwithinthe pastyear,

havingaclinicorhealthcenterastheusualplaceforhealth

care,9_and_hepatitis_B_immunization_were_all_found_to_be

asso-ciatedtoTdapvaccinationinotherstudies.21

TheassociationbetweeninﬂuenzaandTdap

immuniza-tioncouldreﬂectaself-behaviorofsomeHCWs,moreusedto

seekhealthcare,includingimmunization.TheﬁnalTdap

cov-erageobservedamongHCWswithrecommendationofTdap

vaccinationinourhospital(41.2%)wassimilartotheinﬂuenza

vaccinecoveragein2015(43.3%)amongHCWsincludedinthe

study,avaccinethattheyaremoreacquaintedandwhichhas

annualcampaigns.

Educational interventionsand improvedaccessto

vacci-nation, similarto those adoptedfor Tdap,were previously

implementedtoraiseinﬂuenzavaccinecoverageinour

hospi-tal,whichincreasedfrom6.5%in2005to45%in2006.13_In_the

followingyears,inﬂuenzavaccinationattheHCWworkplace

bymobileteamswasmaintainedandthenumberofHCWs

vaccinated was sustained. In 2015, a total of9,678 (48.5%)

(6)

Partially,lowTdapcoveragecouldbeattributedtolower

awareness of the vaccine recommendations since it was

onlyrecentlyintroducedinthecountry.Inourstudy,among

30 HCWs notimmunized,90% reported notknowing Tdap

vaccine. Miller et al.23 _found_a _lower _percentage_in _United

States:39%ofHCWsreportedhavingneverheardofthe

vac-cine.

Wehavenot activelyaccessed adverse events following

immunization(AEFI) during ourvaccination strategies, but

onecaseofhypersensitivityreactionoccurredduring

vaccina-tionbymobileteamattheworkplace.TheHCWwastreated

withintravenouscorticosteroidandantihistamine,withfull

recovery(datanotshown).

Thisstudy has limitations.First, weperformed lectures

onlyforphysicians.Furthermore,vaccinationofHCWsintheir

worksiteswasconductedinjustone-dayperiodineachclinic,

giventheshortageofhumanresources.Theselimitationsmay

explaininpartourlowﬁnalvaccinecoverage.

Inconclusion,TdapcoverageamongHCWswaslowinour

hospital,similarlytootherreportsinliterature.Every

health-care facility should evaluate its vaccination coverage and

promotecontinuoussurveillanceandstrategiestoraiseTdap

uptaketopreventnosocomialpertussisoutbreaks.

Combina-tionofdifferentstrategiesisnecessary,includingincreasing

awarenessondiseaseriskandvaccineeffectiveness,safety

andrecommendations,andimprovingaccesstovaccination.

Ourdatasuggestthatmakingaccesstovaccineseasier,such

asvaccinationatworkplace,atconvenienttimesfortheHCWs

arecritical.Importantly,mobileteamsmust bepreparedto

deal with immediate adverse events following

immuniza-tion,particularlywithhypersensitivityreactions.Finally,new

approachestoreachadults,particularlytheHCWs,toincrease

vaccinescoverageamongthemareneeded.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

Appendix

A. Supplementary

data

Supplementarymaterialrelatedtothisarticlecanbefound,

in the online version, at doi:https://doi.org/10.1016/j.bjid.

2019.06.007.

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