Determinants of Tetanus, Pneumococcal and Influenza Vaccination in the Elderly

A Representative Cross-Sectional Study on Knowledge, Attitude and Practice (KAP)

Carolina J. Klett-Tammen; Gérard Krause; Linda Seefeld; Jördis J. Ott


BMC Public Health. 2016;16(121) 

In This Article


Older age is strongly associated with disease severity and case fatality resulting from Streptococcus pneumoniae (s. pneumoniae),[1] influenza virus infection,[2] and infection with Clostridium tetani.[3] Severe disease outcomes from S. pneumoniae include invasive pneumococcal diseases (IPD),[4] as sepsis, pneumonia,[5] and meningitis,[6] whereas influenza virus infection is characterized by high fever, aching muscles, headache, cough, sore throat and rhinitis. Tetanus mostly presents as a spastic disease, followed by spastic paralysis and death. In Germany, reported incidence of IPD and influenza infection in 2014 was 1.35/100.000 and 5.92/100.000, respectively in the age group 60 years and older. There was no reported case of tetanus.[7] Since there is no nationwide mandatory reporting for IPD in Germany, reported incidence is likely to be substantially underestimated.[8,9] Vaccines against all three diseases are available and German vaccine recommendations for adults aged ≥60 years include the 10 year interval tetanus and diphtheria vaccination, the annual influenza vaccination and a singular pneumococcal vaccination, using the 23-valent PPV dose, while PCV is also licensed.[10] The self-reported vaccination rate in the German 60–79 years old population varies by vaccine type and ranges from 31 % for pneumococcal, to 66 % for influenza and 70 % for tetanus vaccination.[11] While a national campaign promotes influenza vaccination,[12] no comparable strategies are in place for pneumococcal or tetanus vaccination, focusing on the elderly.

Health-related behavior is affected by different aspects of knowledge, attitude and practices (KAP).[13] Reviewing the existing evidence from 69 international publications on determinants of vaccine-usage in the elderly, we found the following to be most frequently significantly associated with vaccine uptake: socio-demographic determinants such as living arrangement,[14] low awareness of the vaccine recommendation,[15,16] attitudes like the perceived low severity of the corresponding disease,[17,18] and practices including previous uptake of vaccinations.[19] Little is known about determinants of uptake of vaccinations in the older German population and how they vary by vaccine type. Furthermore, most studies investigated associations of single variables particularly with influenza vaccine uptake, while less attention is paid to officially recommended tetanus and pneumococcal vaccination.

Using data of a representative national survey on infection prevention, the objective of this study was to assess associations between socio-demographic- and KAP-factors and vaccine uptake in order to identify determinants of vaccine uptake in the elderly. Using multivariate and factor analyses, knowledge-, attitude- and practice-related predictors of tetanus, influenza and pneumococcal vaccination were analysed. Given the high information load created when assessing KAP-variables on an individual level, we tested and applied statistical methods to create scores of variables with statistically significant associations.