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Vaccination Module

Vaccination Module
Background
Influenza infections are associated with increased medical costs, hospitalizations, lost
productivity, and thousands of deaths every year in the United States. The majority of deaths
from seasonal influenza occur in adults aged ≥ 65 years.1-4 Annual influenza vaccination is the
best way to reduce the risk for complications from influenza infections and in the United States
is now recommended for all persons aged ≥ 6 months.
Annual epidemics of seasonal influenza usually occur during the late fall through early spring
each year. During these times, rates of infection with influenza, are highest among persons aged
≥ 65 years of age, in children < 2 years and persons of any age who have medical conditions
placing them at increased risk for the complications of influenza. (5-7) Occasionally, a variant
strain of influenza will emerge that is distinct from the expected seasonal strain and requires a
separate vaccination for prevention. In 2009-10, this non-seasonal strain was novel Influenza A
(H1N1) 2009. Annual influenza vaccination is the most effective way to prevent influenza virus
infection and its complications.
Methodology
The Vaccination Module targets the healthcare facility’s inpatient population, who are greater
than 6 months of age. Two separate approaches (Summary Method or Patient-Level Method) are
used to report data for the Vaccination Module. The module can be completed using either
retrospective medical record review (Summary Method or Patient-Level Method) or prospective
surveillance (Patient-Level Method). Either method may be used during the influenza season.
When vaccinations for more than one subtype are recommended during a season, use a single
method and report data separately for each vaccination subtype. For example, report a Summary
Method record for seasonal vaccination and one for the non-seasonal subtype. Multiple
admissions by the same patient during the same month should be evaluated as separate
encounters for this module.
A trained individual shall initially seek to identify all inpatient admissions as meeting criteria
for seasonal vaccination during the review period, and determine if influenza vaccination was
offered, and then either accepted or declined during the course of the patient’s admission.
Personnel other than the IP may be trained to perform these observations.
The CDC forms 57.130, 57.131, 57.133 are used to collect all required data for this module
depending on whether Summary Method or Patient-Level Method is the selected surveillance
approach.
An optional tool, Influenza Vaccination Standing Orders form (CDC 57.134), is also available to
provide a chart document that will allow for the capture of needed data elements to complete this

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module. The minimum requirement to participate in this module is one month during the
influenza season (September through April), but maximal benefit is obtained by completing the
module for each month of the entire influenza season.

Summary Method
Introduction: The Summary Method requires the use of a single form, the Vaccination Monthly
Monitoring Form – Summary Method (CDC 57.130 and Tables of Instructions, Table 14) to
collect all data for the period of surveillance. There will be a Summary form completed for each
month the facility is following influenza vaccination for the influenza season. This retrospective
method consists of determining the total number of patients in eight separate categories during
the surveillance month(s). The value of this type of surveillance is the simplicity of data
collection requirements.
Settings: This is a facility-wide surveillance in which all NHSN inpatients will be monitored
during the selected month(s).
Requirements: Surveillance will consist of a review of all NHSN inpatients facility-wide to
determine 1) whether they meet criteria for seasonal influenza vaccination, 2) how many were
previously vaccinated, and 3) the number meeting criteria who are offered and receive influenza
vaccination during their admission. Two doses of seasonal influenza vaccine are required for
children 6 months–8 years receiving seasonal influenza vaccine for the first time (see latest
CDC/ ACIP recommendations for details). Ideally, the facility should conduct the surveillance
during each month of the influenza season (September through April).
Definitions: All box numbers refer to boxes on the Vaccination Monthly Monitoring Form–
Summary Method (CDC 57.130).
NHSN inpatient: A patient whose date of admission to the healthcare facility and the date of
discharge are different calendar days.
Total number of patient admissions (Box 1): The count of all NHSN inpatients admitted to the
facility.
Total number of patients aged 6 months and older meeting criteria for influenza vaccination (Box
2): The count of NHSN inpatients meeting criteria for vaccination. Include in this count any
patients who have been previously vaccinated during the current influenza season.
Total number of patients previously vaccinated during current influenza season (Box 3): During
the month selected for surveillance, the count of all NHSN inpatients who had previously
received influenza vaccination during the current influenza season by either history or
documentation. Patients requiring a second vaccine should not be included in the count of those
previously vaccinated.

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Total number of patients meeting criteria not previously vaccinated during the current influenza
season (Box 4): During the month selected for surveillance, the count of NHSN inpatients
meeting criteria (Box 2) minus the count of NHSN inpatients meeting criteria previously
vaccinated during the current influenza season (Box 3).
Patients meeting criteria offered vaccination but declining for reasons other than medical
contraindication (Box 5): The count of NHSN inpatients meeting criteria offered vaccination but
who declined for reasons other than medical contraindication. Refer to Table 1 for examples of
personal (non-medical) reasons for declining vaccination.
Patients meeting criteria offered vaccination but having medical contraindication (Box 6): The
count of NHSN inpatients offered vaccination but who declined because of medical
contraindication(s). Refer to Table 1 for examples of medical contraindication.
Patients meeting criteria receiving vaccination during admission (Box 7): The count of patients
with documentation in the medical record of receiving influenza vaccination during the course of
their hospital admission prior to being discharged.
Total number of patients offered vaccination (Box 8): The sum of the count of all NHSN
inpatients offered vaccination but who declined for reasons other than medical contraindication
(Box 5) plus all patients offered vaccination but who declined because of medical
contraindication (Box 6) plus all NHSN inpatients with documentation in the medical record of
receiving influenza vaccination during the course of their hospital admission prior to being
discharged (Box 7). The number in this box should be less than or equal to the number in Box 4.
Refer also to the Key Terms, Chapter 16, for other definitions.
Numerator and Denominator Data: The numerator and denominator data are reported on the
Vaccination Monthly Monitoring Form–Summary Method (CDC 57.130) in boxes 1-8 for the
month(s) selected for surveillance (Tables of Instructions, Table 14).
Data Analysis: Data aggregated across the entire facility are stratified by time (e.g., month,
influenza subtype, influenza season). Table 2 shows the formulas for metrics that can be
calculated from the Summary Method.

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Table 1: Formulas for Metrics: Summary Method
All data come from Boxes 1-8 of the Vaccination Monthly Monitoring Form–Summary Method
(CDC 57.130)
Summary Formula (x 100)

Metric
1

Prevalence rate for inpatients not previously vaccinated
among all inpatient admissions

2

Adherence rate for offering influenza vaccination to
inpatients among all eligible inpatients
Adherence rate for receiving influenza vaccination by
inpatients among all inpatients
Adherence rate for receiving influenza vaccination by
inpatients among all medically eligible inpatients
Adherence rate for receiving influenza vaccination by
inpatients among all medically eligible, willing inpatients
Declination rate for inpatients eligible for influenza
vaccination among all inpatients offered vaccine
Declination rate due to personal (non-medical) reasons for
inpatients eligible for influenza vaccination among all
inpatients offered vaccine
Declination rate due to medical contraindications for
inpatients eligible for influenza vaccination among all
inpatients offered vaccine
Failure rate for offering vaccine to inpatients medically
eligible for influenza vaccination among all medically
eligible inpatients
Prevalence rate of all inpatients previously vaccinated
during the current influenza season among all inpatient
admissions

3
4
5
6
7

8

9

10

Box 4
Box 1
Box 8
Box 4
Box 7
Box 4
Box 7
Box 4 – Box 6
Box 7
(Box 4 – Box 6) + Box 5
Box 5 + Box 6
Box 8
Box 5
Box 8
Box 6
Box 8
Box 4 – Box 8
Box 4 – Box 6
Box 3
Box 1

Patient-Level Method
Introduction: The Patient-Level Method requires the use of two forms, the Vaccination
Monthly Monitoring Form–Patient-Level Method (CDC 57.131), and the Patient Vaccination
form (CDC 57.133), with Tables of Instructions, Table 14 to collect all data for the period of
surveillance. The patient vaccination forms must be completed when the facility is following
influenza vaccination for inpatients. The value of this method is that the information collected
will assist facilities in identifying whether NHSN inpatients meeting criteria for influenza
vaccination during an admission are actually receiving vaccination, and the details of those

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vaccinations. Additionally, IPs will be able to identify specific gaps in adherence and
recommend changes in practices to ensure that eligible patients are being vaccinated.
Settings: This is a facility-wide surveillance in which all NHSN inpatients will be monitored
during the selected month(s).
Requirements: Surveillance will consist of a review of all NHSN inpatients facility-wide to
determine whether they meet criteria for influenza vaccination who are offered and receive
influenza vaccination during the course of their admission. Surveillance must be conducted for at
least one calendar month during the influenza season as indicated in the Patient Safety Monthly
Reporting Plan (CDC 57.106). During seasons when seasonal and non-seasonal subtype
vaccinations are recommended, such as 2009-10, monitoring is required for all influenza
vaccinations, unless both doses have been received. Patients requiring a second vaccine
shouldn’t be included in the count of those previously vaccinated. A Vaccination Monthly
Monitoring Form–Patient-Level Method (CDC 57.131) and a Patient Vaccination form (CDC
57.133) need to be completed for each of the 2 doses given. (See latest CDC/ACIP
recommendations for current season details). Ideally the facility should conduct the surveillance
during each month of the influenza season (September through April).
The Patient-Level Method requires determination of the number of NHSN inpatients in the
following categories for the month selected for review. (All box numbers refer to the boxes
found on the Vaccination Monthly Monitoring Form–Patient-Level Method [CDC 57.131]):
•
Total number of NHSN patient admissions (Box 1).
•
Total number of NHSN patients previously vaccinated during the current influenza season
(Box 2).
In addition, all NHSN inpatient admissions found to meet criteria for influenza vaccination but
not previously vaccinated during the current influenza season will need to have a Patient
Vaccination form (CDC 57.133) completed as indicated. For those patients who decline
influenza vaccination, reasons for declination (medical contraindications and personal) are
captured (Table 2).
Table 2: Examples of Medical Contraindications to Influenza Vaccination and of
Personal Reasons for Declining Influenza Vaccinations
Medical Contraindications
Allergy to vaccine components
History of Guillain-Barré syndrome within 6 weeks of
previous influenza vaccination
Current febrile illness (Temp > 101.5°)
Personal (non-medical) reasons for Fear of needles/injections
declining vaccination
Fear of side effects
Perceived ineffectiveness of vaccine
Religious or philosophical objections
Concern for transmitting vaccine virus to contacts

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Review all NHSN inpatient admissions and determine whether they meet the criteria for
influenza vaccination. Note that all NHSN inpatients that meet criteria but have previously been
vaccinated during the current influenza season do not require a Patient Vaccination form (CDC
57.133) to be completed, but should be totaled and entered on the Vaccination Monthly
Monitoring Form–Patient-Level Method (CDC 57.131) in Box 2.
Definitions: All box numbers refer to the boxes found on the Vaccination Monthly Monitoring
Form–Patient-Level Method (CDC 57.131).
NHSN Inpatient: A patient whose date of admission to the healthcare facility and the date of
discharge are different calendar days.
Total number of patient admissions (Box 1): The count of all NHSN inpatients admitted to the
facility.
Total number of patients previously vaccinated during the current influenza season (Box 2): The
count of all NHSN inpatients who had previously received influenza vaccination during the
current influenza season by either history or documentation. Patients requiring a second vaccine
should not be included in the count of those previously vaccinated, unless both doses have been
received.
Refer also to the NHSN Key Terms, Chapter 16, for other definitions.
Numerator and Denominator Data: Numerator data are reported on the Patient Vaccination
form (CDC 57.133). In addition, some numerator and denominator data are reported on the
Vaccination Monthly Monitoring Form–Patient-Level Method (CDC 57.131).
Data Analysis: Data aggregated across the entire facility are stratified by time (e.g., month,
influenza subtype, influenza season). Table 3 shows the formulas for metrics that can be
calculated from the Patient-Level Method.

Table 3: Formulas for Metrics: Patient-Level Method
Data come from two CDC forms:
Boxes 1 - 4 of the Vaccination Monthly Monitoring Form–Patient-Level Method (CDC 57.131)
Patient Vaccination (PV) form (CDC 57.133)
Metric
Patient Vaccination Formula (x 100)
1

Prevalence rate for inpatients
not previously vaccinated
among all inpatient
admissions

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Table 3: Formulas for Metrics: Patient-Level Method
Data come from two CDC forms:
Boxes 1 - 4 of the Vaccination Monthly Monitoring Form–Patient-Level Method (CDC 57.131)
Patient Vaccination (PV) form (CDC 57.133)
Metric
Patient Vaccination Formula (x 100)
2

3

4

5

6

7

8

9

Adherence rate for offering
Total # PV Forms “Vaccine offered” = “Yes”
influenza vaccination to
Box 4
inpatients among all eligible
inpatients
Adherence rate for receiving
Total # PV Forms “Vaccine administered” = “Yes”
influenza vaccination
Box 4
inpatients among all inpatients
Adherence rate for receiving
Total # PV Forms) “Vaccine administered” = “Yes”
influenza vaccination by
Box 4 – Total # PV Forms “Vaccine declined” = “Yes”
inpatients among all medically
due to medical contraindications
eligible inpatients
Adherence rate for receiving
Total # PV Forms “Vaccine administered” = “Yes”
influenza vaccination by
(Box 4 –Total # PV Forms “Vaccine declined = “Yes” due to
inpatients among all medically medical contraindication) + “Vaccine declined” = “Yes” due
eligible, willing inpatients
to personal reasons
Declination rate for inpatients
eligible for influenza
Total # PV Forms “Vaccine declined” = “Yes”
Total # PV Forms “Vaccine offered = “Yes”
vaccination among all
inpatients offered vaccine
Declination rate due to
personal (non-medical)
Total # PV Forms
reasons for inpatients eligible
“Vaccine declined” = “Yes” due to personal reasons
for influenza vaccination
Total # PV Forms “Vaccine offered” = “Yes”
among all inpatients offered
vaccine
Declination rate due to
Total # PV Forms
medical contraindications for
“Vaccine declined” = “Yes” due to medical
inpatients eligible for
contraindications
influenza vaccination among
Total # PV Forms “Vaccine offered”= “Yes”
all inpatients offered vaccine
Failure rate for offering
vaccine to inpatients
medically eligible for
Box 4 – Total # PV Forms “Vaccine offered” = “Yes”
influenza vaccination among
“Vaccine declined” = “Yes” due to medical contraindications
all medically eligible
inpatients

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Table 3: Formulas for Metrics: Patient-Level Method
Data come from two CDC forms:
Boxes 1 - 4 of the Vaccination Monthly Monitoring Form–Patient-Level Method (CDC 57.131)
Patient Vaccination (PV) form (CDC 57.133)
Metric
Patient Vaccination Formula (x 100)
10

Prevalence rate of all
inpatients previously
vaccinated among all inpatient
admissions

Box 3
Box 1

Optional Standing Orders Form for Influenza Vaccination Data Collection
An optional Influenza Vaccination Standing Orders form (CDC 57.134) can be used as part of an
inpatient medical record is available as part of this module to assist with data collection. See
Tables of Instructions, Table 18, for completion instructions.

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References
1.
Simonsen L, Reichert TA, Viboud C, Blackwelder WC, Taylor RJ, Miller MA. Impact of
Influenza Vaccination on Seasonal Mortality in the US Elderly Population. Arch Intern Med.
2005;165(3):265-72.
2.
Thompson WW, Moore MR, Weintraub E, Cheng PY, Jin X, Bridges CB, et al.
Estimating influenza-associated deaths in the United States. Am J Public Health. 2009;99 Suppl
2:S225-30.
3.
Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, et al.
Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA.
2003;289(2):179-86.
4.
Thompson WW, Weintraub E, Dhankhar P, Cheng PY, Brammer L, Meltzer MI, et al.
Estimates of US influenza-associated deaths made using four different methods. Influenza Other
Respi Viruses. 2009;3(1):37-49.
5.
Barker WH. Excess pneumonia and influenza associated hospitalization during influenza
epidemics in the United States, 1970-78. Am J Public Health. 1986;76(7):761-5. PMCID:
1646876.
6.
Barker WH, Mullooly JP. Impact of epidemic type A influenza in a defined adult
population. Am J Epidemiol. 1980;112(6):798-811.
7.
Monto AS, Kioumehr F. The Tecumseh Study of Respiratory Illness. IX. Occurence of
influenza in the community, 1966--1971. Am J Epidemiol. 1975;102(6):553-63.

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