Ability of Healthcare Workers to Recall Previous Receipt of Tetanus‐Containing Vaccination • Author(s): Jose‐Mario Fontanilla, MD, MPH; Kathryn B. Kirkland, MD; J. Gavin Cotter, MD,MPH; Elizabeth A. Talbot, MDSource: Infection Control and Hospital Epidemiology, Vol. 31, No. 6 (June 2010), pp. 647-649Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiologyof AmericaStable URL: http://www.jstor.org/stable/10.1086/652771 .

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infection control and hospital epidemiology june 2010, vol. 31, no. 6

c o n c i s e c o m m u n i c a t i o n

Ability of Healthcare Workers to RecallPrevious Receipt of Tetanus-ContainingVaccination

Jose-Mario Fontanilla, MD, MPH;Kathryn B. Kirkland, MD; J. Gavin Cotter, MD, MPH;Elizabeth A. Talbot, MD

Vaccination of healthcare workers (HCWs) is an important strategyin the control and prevention of hospital outbreaks. The decisionto vaccinate is often based on self-report of vaccination status. Self-report of previous receipt of tetanus-diphtheria or tetanus toxinvaccination was validated using an electronic medical record. Re-sults showed that HCWs’ self-report is reliable during a vaccina-tion campaign.

Infect Control Hosp Epidemiol 2010; 31(6):647-649

Self-report of immunization status is commonly used to guidedecisions on whether certain vaccinations are indicated dur-ing a clinical encounter and to measure national immuni-zation rates. Large national surveys, such as the MedicareBeneficiary Survey, the Behavioral Risk Surveillance System,and the National Health Interview Survey, depend on self-report of data.1 Determining the validity of self-report in theassessment of vaccination status is important, because reli-ance on patient recall may lead to either nonimmunizationof patients at risk or undue exposure to possible adverseeffects. Healthcare workers (HCWs) constitute a special groupfor vaccination, because of the increased risk of exposure toand transmission of vaccine-preventable diseases.

As a response to an outbreak of a respiratory illness thatwas initially thought to be compatible with pertussis,2 a hos-pital-wide tetanus-diphtheria–acellular pertussis (Tdap) vac-cination campaign was undertaken. Although the recom-mendation of the Advisory Committee on ImmunizationPractices is that Tdap be administered to HCWs who hadmost recently received tetanus-diphtheria or tetanus toxinvaccination more than 2 years earlier,3 the hospital admin-istration offered the vaccination to all HCWs, because of theseverity of the outbreak. In this study, we assessed HCWs’ability to accurately report whether they had most recentlyreceived a tetanus-containing vaccination within the previ-ous 2 years or more than 2 years earlier.

methods

During the vaccination campaign, HCWs were asked to com-plete a survey that inquired about their vaccination historyand their reaction to the Tdap vaccination that they had justreceived. Study participants were defined as HCWs who re-sponded to the question about whether they had most re-cently received a tetanus-containing vaccination more than2 years earlier and who had any vaccination history in theirelectronic medical record (EMR). We defined HCWs in ac-cordance with the definition of the Healthcare Infection Con-trol Practices Advisory Committee and the Advisory Com-mittee on Immunization Practices.4 The self-report wasvalidated using the EMR. This research was reviewed andapproved by the Dartmouth Committee for the Protectionof Human Subjects.

results

During the immunization campaign, 6,289 HCWs were eli-gible for vaccination, and 4,524 HCWs (71.9%) received Tdapvaccination. Of those 4,524 HCWs, 2,676 (59.2%) completedthe survey questionnaire. The question about the timing oftheir most recent receipt of tetanus-containing vaccinationwas answered by 2,260 HCWs, and 328 of these HCWs hadvaccination information in the EMR (Table 1). There weresignificantly more female than male HCWs in the populationsurveyed ( , by the x2 test). Also, the percentage ofP p .03HCWs who reported most recent receipt of vaccinationwithin the previous 2 years was significantly higher in thevalidation study sample, compared with the correspondingpercentage in the population surveyed ( , by the x2P p .02test) (Table 1).

Of the 328 self-reports that were compared with the EMR,306 (93.3%) were validated by the EMR. Among the 253 self-reports of most recent receipt of a tetanus-containing vac-cination more than 2 years earlier, 243 (96%) were validatedby the EMR. Among the 75 self-reports of most recent receiptof a tetanus-containing vaccination within the previous 2years, 63 (84%) were confirmed by the EMR. The concor-dance rate between the self-report and the EMR was signif-icantly lower in the group that reported most recent receiptto be within the previous 2 years ( ). The discrepancyP ! .01between the reported tetanus-containing vaccination date andthe documented tetanus-containing vaccination date ranged1–84 months (Figure 1).

discussion

In this study, HCWs accurately recalled and reported previousreceipt of tetanus-containing vaccination. The high concor-

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648 infection control and hospital epidemiology june 2010, vol. 31, no. 6

table 1. Data on Healthcare Workers (HCWs) Who Responded to a Survey of Most Recent Receiptof Tetanus-Containing Vaccination

Characteristic

Total surveypopulation

(n p 2,676)

Validationstudy samplea

(n p 328)

Female sex, no. (%) 2,100 (78.5) 274 (83.5)Median age, years 46 49Responded to question about whether they had most recently received

a tetanus-containing vaccination more than 2 years earlierMost recent receipt “within previous 2 years” 400 75Most recent receipt “more than 2 years earlier” 1,860 253

a The validation study sample was composed of HCWs who responded to the question about whether they had mostrecently received a tetanus-containing vaccination more than 2 years earlier and who had any vaccination history intheir electronic medical record.

figure 1. Flow chart of validation study results. EMR, electronicmedical record; HCP, healthcare personnel; Td/TT, tetanus-diph-theria or tetanus toxin vaccination; Tdap, tetanus-diphtheria–acel-lular pertussis vaccination.

dance of HCWs’ self-report with the EMR may reflect a highlevel of awareness in this population of their own increasedrisk for disease and the benefits of immunization as well asthe ability of HCWs to access their own EMRs. In our in-stitution, all patients, including the HCWs in this study, mayread their medical records, and a number may have checkedtheir status with regard to tetanus-containing vaccination be-fore presenting themselves for evaluation.

Not much is known on the reliability of self-reporting ofimmunization status by HCWs. LeardMann et al5 in 2007looked at the reliability of self-report of smallpox vaccinationby HCWs, first responders, and military personnel2 and foundthat 10% of those who received the vaccination did not re-member receiving it and that 18% of those who did notreceive the vaccination reported being vaccinated. On theother hand, a number of studies have investigated the ac-curacy of patient self-report with variable results. Confir-mation with the medical record showed that self-reportingof influenza vaccination had excellent sensitivity, moderatespecificity, and high positive predictive value.1,6 Recall forpneumococcal vaccination had high sensitivity but only mod-erate specificity and positive predictive value.1,6 In both cases,self-reported vaccination rates tended to be higher than vac-cination rates generated using medical record documen-tation.1,6 In the study by Fishbein et al7 in 2006, self-reportingfor influenza and pneumococcal vaccinations also showedhigh reliability, compared with the medical record, but self-reporting for measles, mumps, and rubella vaccination andfor tetanus-diphtheria vaccination had moderate sensitivity,low specificity, and low positive predictive value. With regardto the reliability of reported tetanus vaccination histories inpatients presenting at the emergency department, Gindi etal8 in 2004 reported that only 43.8% of patients who assertedthat they had received the vaccination in the previous 5 yearswere confirmed to have received it with the medical recordand/or a positive history of skin break. Differences in patientdemographic characteristics (eg, age, education level, and so-cioeconomic status) and in the actual vaccination schedules(eg, annual influenza vaccination or tetanus vaccination every

10 years) in these studies may explain the different findings.It is difficult to determine how much these findings wouldapply to HCWs because of the presumed difference in medicalknowledge and awareness.

A limitation of this study was the use of convenience sam-pling. We included only HCWs who responded to the surveyquestion about the timing of the most recent receipt of tet-anus-containing vaccination and who had vaccination infor-mation in the institution’s EMR. Furthermore, although themedical record has generally been used as the gold standardfor validation of self-report of vaccination, improper docu-mentation may lead to error.

In this study, we found that HCWs can accurately remem-ber their tetanus vaccination history during an outbreak.There is a need for more data to increase confidence in de-cisions for vaccinating on the basis of HCWs’ self-report.

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ability of hcws to recall previous tetanus-containing vaccination 649

acknowledgments

Potential conflicts of interest. All authors report no conflicts of interest rel-evant to this article.

From the Dartmouth Hitchcock Medical Center, Lebanon (J.-M.F., K.B.K.,J.G.C., E.A.T.), the Dartmouth Medical School, Hanover (K.B.K., E.A.T.),and the New Hampshire Department of Health and Human Services, Con-cord (E.A.T.), New Hampshire.

Address reprint requests to Jose-Mario Fontanilla, MD, MPH, 1249 5thSt, Huntington, WV 25701 (jmfontanilla@yahoo.com).

Received August 3, 2009; accepted November 12, 2009; electronically pub-lished April 26, 2010.� 2010 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2010/3106-0015$15.00. DOI: 10.1086/652771

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