PONE-D-21-08907

Influenza vaccination coverage among emergency department personnel is associated with perception of vaccination and side effects, vaccination availability on site and the COVID-19 pandemic

PLOS ONE

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3. Please provide the names of the participating EDs.

4. please provide the date ranges when surveys were collected during the two seasons.

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The authors present the results of two cross-sectional surveys of influenza vaccination uptake among ED personnel in Bavaria, Germany. The manuscript is well-written for the most part and the study findings are generally of interest; the methods require some clarification and the discussion section needs to be reworked. Specific suggests are as follows:

Abstract, line 27: The extremely low response rate in 2020-2021 is a threat to the validity of your findings and should be noted in the limitations section (which is missing from the paper).

Abstract, line 33: The pandemic is not a factor that differs across the study population; this could be tweaked to say something like "the effect of the pandemic on influenza vaccination intentions" or similar.

Introduction, line 52: Usually influenza vaccination is also recommended for those at increased risk of complications from influenza disease, regardless of their risk of acquiring influenza -- this could be noted here as well.

Methods, line 76: Given that the article presents a comparison with findings in the COVID-19 pandemic context and the earlier findings, it would be useful to include a brief note here or in the introduction about the impetus for the initial 2016-2017 survey -- i.e. was it motivated by a specific data point, a policy change, some other global context?

Methods, line 77: Are these 14 EDs the universe of EDs in Bavaria? If not, how many are there/what percentage is represented by the 14 invited, and how were they selected for recruitment?

Methods, lines 89-99: The sample selection requires substantial clarification. Were the 229 and 498 staff surveyed in each season all of the staff working in the ED -- or all of the physicians, nurses, and 'administrative' staff? (And if the latter, which types of staff does this exclude?) If this was not 100% of the staff in the targeted EDs, what proportion is represented by the disseminated and returned surveys? Also, please provide more detail on how specifically the surveys were disseminated -- e.g. were they mailed to individual staff? Was a package of surveys sent to the ED and distributed by a chief/leader? Was the package sent and the surveys were left on a table in the lunch room? Etc. If surveys were not addressed to individuals and they were returned anonymously, how did the authors assure that only targeted staff (from the ED) completed and returned surveys and that multiple surveys were not completed by a single person?

Results, Table 1: Please change "vaccinated because of COVID-19" to "intending to be vaccinated because..." or similar. As written it is confusing to see entries in the 'unvaccinated' category for this variable as the unvaccinated people clearly were not vaccinated because of COVID-19. I will also note that I found this table extremely difficult to follow; you might consider reformatting it or even breaking it up into multiple tables if the space allotted by the journal permits.

Results, line 148: The fact that the comparisons of unvaccinated with vaccinated persons include only data from 2020-21 should be noted at every point in the manuscript or tables/figures where these comparisons are made.

Results, line 157: Higher risk relative to what, or whom? E.g. higher than the general public, higher than doctors...?

Results, line 160: For this and all of the figures, the figure titles need to be more descriptive so that they can be interpreted without reading the text. I would also suggest including in the figure title that the figures compare 2016-17 to 2020-21 and compare unvaccinated to vaccinated persons.

Results, line 169: How was this list of possible vaccine side effects selected? Skin necrosis and encephalitis are essentially nonexistent as a result of influenza vaccination, whereas mild systemic symptoms and injection site pain would commonly be expected. Also, how were these presented in the survey? Listing very serious and extremely rare side effects alongside mild and common side effects could potentially bias respondents' selections.

Results, line 184: As noted above, you would need to emphasize here that this comparison was only done for 2020-2021 -- however, did you attempt to combine data across seasons to see if the same associations with vaccination status persist? (I assume this comparison was not made for 2016-2017 due to the small sample of people vaccinated; however, this could be clarified in the text as well.)

Discussion, general comment: The discussion substantially reiterates the introduction and results sections. Repetitive content should be streamlined so additional interpretation of findings can be excluded. Areas that seem redundant and could be deleted entirely or reduced to a single sentence include lines 213-217 and 223-230.

Discussion, lines 201-206: This should be noted in detail in the introduction as context and then briefly restated here in the discussion if needed.

Discussion, lines 207-212: Some of this is already in the introduction and could be deleted; the parts that are not in the introduction already might more properly belong there as they provide justification for the importance of this study.

Discussion, lines 231-234: It would be helpful here to include some suggested actions to take based on these findings or at least the implications of the findings as nurses presumably provide substantial amounts of care in the ED and are at least equally as much at risk of acquiring and transmitting influenza as physicians.

Discussion, lines 236-239: It's confusing when you bounce back and forth between the comparison across time and the comparison of unvaccinated with vaccinated personnel in the 2020-2021 season. I would recommend a discussion paragraph talking about differences and similarities over time, and then a separate paragraph discussing differences observed by vaccination status in 2020-2021.

Discussion, lines 249-250: Beyond the question of vaccination mandates, I have never seen a published study that examines ethical attitudes and their association with influenza vaccination before -- at least not with a suite of items used together like this. In my view, this is an unique and significant contribution of your study. I would create a separate paragraph focusing on the ethics questions/findings and implications for pandemic preparedness, vaccination promotion, etc.

Discussion, line 259: As noted above, the manuscript lacks a limitations section; one should be added here.

Conclusion, line 261: I did not see a measure of awareness in this study; this should be rephrased to reflect what was actually asked in the survey.

Conclusion, lines 263-264: This finding is extremely important for increasing rates of influenza vaccination in Bavarian EDs because it is actionable and the necessary intervention is obvious. I strongly suggest adding to your discussion a supporting paragraph that discusses the change in onsite vaccine offering over time, any national or regional policies or practices that might support or be a barrier to this (e.g. do Germans have nationalized or private healthcare that might complicate payment; is there a national or regional policy to provide free influenza vaccine to healthcare workers; is there a national or regional target for influenza vaccination, etc.). It might be useful to cite the findings of the U.S. Task Force on Community Preventive Services, which found strong evidence that offering vaccination onsite increases vaccination coverage. Although the Task Force is convened in the U.S., the evidence considered is global and the findings are certainly applicable to the Bavarian context: https://www.thecommunityguide.org/findings/worksite-health-seasonal-influenza-vaccinations-healthcare-on-site. In conjunction with this, some of the studies in other countries noting the association of onsite offering of vaccine with vaccination uptake among HCP could be included.

Conclusion, lines 266-267: I am not aware of any evidence that education/communication campaigns when used alone are effective in increasing vaccination uptake, so I would not term these "most beneficial". I suggest recommending this type of effort in conjunction with onsite offering of influenza vaccine as discussed above.

Figures 2-4: The labels on individual figure entries need to be edited to be more specific as many are not interpretable without a copy of the survey instrument - and this would not be helpful to readers who do not speak German. I would recommend an appendix with the translated survey instrument, but if this is cost- or time-prohibitive, the labels for each entry in the figure should be written as complete phrases or sentences that capture what was actually presented to survey respondents, e.g. "I believe influenza results in death at this frequency" instead of "influenza complications - death".

Reviewer #2: This article is well written. Methodology seems sound. Conclusions were pretty predictable.

I have three questions :

1- Could the authors please elaborate on the fact that vaccination was not available on sit everywhere ? It seems odd that it is not the case in every setting. Could you please describe what health care workers have to do to be vaccinated when flu vaccine is not available on site ?

2- Do they authors have the 2020/2021 national vaccination coverage in physicians and nurses as a comparator ?

3- Could you precise others categories than administrative personnel in the non physicians or nurses people ? Did you survey other personnels in contact with patients such as cargivers known for their low vaccine coverage (even lower than nurses’ one) ?

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Reviewer #1: No

Reviewer #2: Yes: Paul Loubet

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Influenza vaccination coverage among emergency department personnel is associated with perception of vaccination and side effects, vaccination availability on site and the COVID-19 pandemic

PONE-D-21-08907R1

Dear Dr. Hanses,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. As one of the previous reviewers (Reviewer #1), I found your revision to be extremely responsive to all of my comments and I appreciate your time in carefully addressing each of the stated concerns. The revised manuscript provides the necessary context for your findings and is organized in a way to highlight the comparisons made over time as well as by vaccination status and the unique contribution of the ethical/values data gathered. 

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Megan C. Lindley

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

The authors' conscientious response to the previous review comments is much appreciated. The revised manuscript is much improved and highlights the unique contributions of the authors' research.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Thank you for having adressed my comments. I have no other comments

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #2: Yes: Paul Loubet