How can we increase seasonal influenza vaccine coverage in nursing home residents?

In the November issue of the Journal, a very interesting letter to the editor reports the results of a questionnaire revealing the reasons why competent Chinese nursing home residents refuse to get the seasonal flu vaccine.1 To the best of my knowledge, this is the only survey to report direct one-to-one answers from nursing home residents, although a similar survey was previously reported in college students.2 Nursing home residents who were mentally competent to answer the questionnaire (mean age 79.0 9.7 years) accepted to be vaccinated depending on the information given by nursing health care workers (nHCWs) and relatives.1 However, a significant number of nursing home residents refused to be vaccinated for 2 main reasons; namely, they perceived influenza infection as “mild/not severe” and considered the vaccine to be “nonefficacious.”1 Surprisingly, no other refusal reason appeared significant, which clearly demonstrates the lack of knowledge of the disease on the part of nursing home residents, their relatives, and nHCWs, whose general lack of information about influenza vaccine likely influences their willingness to promote it among their patients.3 The primary cause of this lack of information is that, until now, vaccines were considered useful only in children, and not in aging and aged adults. However, there are currently 200 times more deaths each year in the United States from vaccine-preventable infectious diseases in older adults than in children.4 This imbalance is striking, and reflects a number of underlying educational, structural, economic, cultural, and political issues.4 Clearly, influenza is much more severe than generally thought. In Europe, the number of excess deaths associated with influenza was estimated to be between 40,000 and 220,000, depending on the seasonal variation strains.5 It is well known that most influenzarelated and pneumococcal disease deaths occur in people 65 years or older.6,7 This excess mortality is not only linked to the aforementioned infectious diseases themselves, but also to pulmonary tract reinfections, health careeassociated infections and antimicrobial resistance, or cardioand neurovascular complications occurring in frail older and disabled adults.8 Indeed, the efficacy of vaccination of older nursing home residents remains debated. The results of cohort studies of vaccination in