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Examining Perceptions about Mandatory Influenza Vaccination of Healthcare Workers through Online Comments… Lei, Yang; Pereira, Jennifer A.; Quach, Susan; Bettinger, Julie A.; Kwong, Jeffrey C.; Corace, Kimberly; Garber, Gary; Feinberg, Yael; Guay, Maryse 2015

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RESEARCH ARTICLEExamining Perceptions about MandatoryInfluenza Vaccination of Healthcare Workersthrough Online Comments on News StoriesYang Lei1,2, Jennifer A. Pereira1, Susan Quach1, Julie A. Bettinger3,4,5, JeffreyC. Kwong1,6,7,8,9, Kimberly Corace10,11,12, Gary Garber1,2,10,11, Yael Feinberg1,2,Maryse Guay13,14,15,16*, Public Health Agency of Canada/Canadian Institutes of HealthResearch Influenza Research Network (PCIRN) Program Delivery and Evaluation Group1 Public Health Ontario, Toronto, ON, Canada, 2 University of Toronto Faculty of Medicine, Toronto, ON,Canada, 3 Vaccine Evaluation Center, Vancouver, BC, Canada, 4 BC Children’s Hospital, Vancouver, BC,Canada, 5 University of British Columbia, Vancouver, BC, Canada, 6 Dalla Lana School of Public Health,University of Toronto, Toronto, ON, Canada, 7 Institute for Clinical Evaluative Sciences, Toronto, ON,Canada, 8 Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada,9 University Health Network, Toronto, ON, Canada, 10 The Ottawa Hospital, Ottawa, ON, Canada,11 University of Ottawa, Ottawa, ON, Canada, 12 University of Ottawa Institute of Mental Health Research,Ottawa, ON, Canada, 13 Département des sciences de la santé communautaire, Université de Sherbrooke,Longueuil, QC, Canada, 14 Institut national de santé publique du Québec, Longueuil, QC, Canada,15 Centre de recherche de l’Hôpital Charles LeMoyne, Longueuil, QC, Canada, 16 Agence de la santé etdes services sociaux de la Montérégie, Longueuil, QC, Canada* maryse.guay.agence16@ssss.gouv.qc.caAbstractBackgroundThe aim of this study was to understand online public perceptions of the debate surroundingthe choice of annual influenza vaccinations or wearing masks as a condition of employmentfor healthcare workers, such as the one enacted in British Columbia in August 2012.MethodsFour national and 82 local (British Columbia) Canadian online news sites were searched forarticles posted between August 2012 and May 2013 containing the words “healthcare work-ers” and “mandatory influenza vaccinations/immunizations” or “mandatory flu shots andhealthcare workers.”We included articles from sources that predominantly concerned ourtopic of interest and that generated reader comments. Two researchers coded the uneditedcomments using thematic analysis, categorizing codes to allow themes to emerge. In addi-tion to themes, the comments were categorized by: 1) sentiment towards influenza vac-cines; 2) support for mandatory vaccination policies; 3) citing of reference materials orstatistics; 4) self-identified health-care worker status; and 5) sharing of a personal story.Results1163 comments made by 648 commenters responding to 36 articles were analyzed. Popu-lar themes included concerns about freedom of choice, vaccine effectiveness, patientPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 1 / 12a11111OPEN ACCESSCitation: Lei Y, Pereira JA, Quach S, Bettinger JA,Kwong JC, Corace K, et al. (2015) ExaminingPerceptions about Mandatory Influenza Vaccinationof Healthcare Workers through Online Comments onNews Stories. PLoS ONE 10(6): e0129993.doi:10.1371/journal.pone.0129993Academic Editor: Chris T. Bauch, University ofWaterloo, CANADAReceived: February 27, 2015Accepted: May 16, 2015Published: June 18, 2015Copyright: © 2015 Lei et al. This is an open accessarticle distributed under the terms of the CreativeCommons Attribution License, which permitsunrestricted use, distribution, and reproduction in anymedium, provided the original author and source arecredited.Data Availability Statement: All relevant data arewithin the paper and its Supporting Information files.Funding: The authors received no specific fundingfor this work.Competing Interests: The authors have declaredthat no competing interests exist.safety, and distrust in government, public health, and the pharmaceutical industry. Almosthalf (48%) of commenters expressed a negative sentiment toward the influenza vaccine,28% were positive, 20% were neutral, and 4% expressed mixed sentiment. Of those whocommented on the policy, 75% did not support the condition to work policy, while 25% werein favour. Of the commenters, 11% self-identified as healthcare workers, 13% shared per-sonal stories, and 18% cited a reference or statistic.InterpretationThe perception of the influenza vaccine in the comment sections of online news sites is fair-ly poor. Public health agencies should consider including online forums, comment sections,and social media sites as part of their communication channels to correct misinformation re-garding the benefits of HCW influenza immunization and the effectiveness of the vaccine.BackgroundSeasonal influenza carries a high burden of disease, especially in persons aged65 years or<2years [1–3]. Vaccinating health care workers (HCWs) against influenza is an effective strategyto prevent transmission in healthcare settings [4]. Yet despite the widespread availability of thevaccine and strong recommendations for HCW influenza immunization, coverage in manyCanadian healthcare organizations is low (40–60%) [5–7].Some healthcare institutions in the United States have introduced policies making influenzavaccination a condition of work for HCWs, leading to vaccine coverage levels exceeding 90%[8–12]. In 2000, the Ontario Ministry of Health and Long-Term Care attempted to legislatemandatory influenza vaccination for paramedics, a policy that was repealed after HCWs chal-lenged it for violating personal autonomy. No other Canadian province tried to implementmandatory vaccination until 2012, when the British Columbia (BC) Ministry of Health an-nounced a policy of either influenza vaccination or wearing a mask during influenza season asa condition of service for HCWs [13]. Elsewhere in Canada, Horizon Health Network, one ofthe two health authorities in New Brunswick, implemented a similar policy in 2012, as did 13Ontario hospitals in 2013 and 12 Toronto-area academic hospitals in 2014 [14], and the prov-ince of Saskatchewan in September 2014[15]. The policies in Ontario, New Brunswick, andSaskatchewan have not been legally challenged and are still in place. However, the province-wide BC condition of service policy was controversial among HCWs and resulted in a legalchallenge by the nursing union. The policy was upheld in arbitration in October 2013[16].Given the media attention around the BC policy (S1 Table), it is important to understandthe perceptions of the general public towards influenza vaccination as a condition of service forHCWs. This is because online comments may influence the opinions of other content consum-ers—including HCWs—through the effects of exemplification [17–20], and may subsequentlyerode confidence in vaccines in general. We chose to focus on the comment sections of onlinenewspapers since nearly 75% of Canadians read a newspaper each week, of which 42% read on-line content [21]. The advantages of analyzing perception data derived from social media arethat they are readily available and can be drawn from a large geographic area [22]. Readersposting on major news sites may be more honest about their opinions since a certain degree ofanonymity can be maintained. In addition, compared to other forms of social media such asTwitter, users can post more detailed opinions without restriction on the number of characters.Perceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 2 / 12The disadvantages include the fact that the population of online commenter do not necessarilyreflect the general population, or HCWs, and that more negative voices tend to be more vocalonline [23]. To understand Canadians’ perceptions of the seasonal influenza vaccination as acondition of service for HCWs, we evaluated readers’ responses to online newspaper articlesafter the BC policy was announced but before it was upheld in arbitration [16].MethodsData sourcesWe searched four national and 82 local (BC) Canadian online English language news sites fornews articles about mandatory influenza vaccination policies for HCWs (Fig 1). We focused onBC, given that the condition of service policy was introduced province-wide for the 2012–13Fig 1. Search strategy and inclusion criteria. An initial search returned 143 articles from which we filtered down to 36 articles containing 1163 comments.doi:10.1371/journal.pone.0129993.g001Perceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 3 / 12influenza season, and therefore the majority of press coverage would be from that province.We used an online newspaper database to identify BC news sites [24].We considered English news articles posted between when the policy was announced by theProvincial Health Officer, on August 23, 2012, and the last day before our analysis began, onMay 31, 2013, inclusive. We only considered English language articles since the Francophonecommunity in BC is very small and the topic was not covered by newspapers in Quebec. Arti-cles were included if they contained the words “healthcare worker” and “mandatory influenzavaccinations/immunizations” or “mandatory flu shots and healthcare workers.” Each article wasreviewed to ensure that they predominantly pertained to the topic of mandatory influenza vac-cinations for HCWs and had at least one comment.AnalysisDescriptive analysis. We summarized descriptive statistics for sentiment toward both sea-sonal influenza vaccines and the BC condition of work policy, and number of comments perindividual. Individuals were defined as having a unique profile name associated with their com-ment. Some news sites allowed readers to enter comments under a “Guest” profile. For thesecomments, we counted each “Guest” as a unique individual. For each comment, we recordedwhether it included an influenza vaccine-related statistic or a link to a website, whether it con-tained a personal story, and whether the individual self-identified as a HCW. We combinedmultiple comments from the same username on the same article as one user. In reading thefirst 50 comments, we identified three main patterns, and began to categorize each user intothree groups: 1) those who do not believe in the effectiveness of seasonal influenza vaccines,and do not support vaccination as a condition of service for HCWs; 2) those who do believe inthe effectiveness of seasonal influenza vaccines, and do support vaccination as a condition ofservice for HCWs; and 3) those who do believe in the effectiveness of seasonal influenza vac-cines, but do not support vaccination as a condition of service for HCWs.Qualitative analysis. Using the process of thematic analysis [25], two researchers (S.Q.and Y.L.) co-coded 20% of the unedited comments independently, generating a coding dictio-nary that was based on the first 50 comments, and adding codes as required. After conferringand reaching consensus on the finalized coding list, S.Q. coded 30% and Y.L. coded 70% of theremaining comments. Next, the codes were organized into themes and the research team re-viewed the results together to ensure that both clinical and methodological perspectives werebrought to the analysis. Each comment could contain multiple themes. The length of the com-ment was not considered. All analyses were conducted using QSR NVivo 10.ResultsOur online searches of media sites identified 36 articles that met our inclusion criteria, with 21national articles, and 15 articles from BC newspapers (Fig 1). The majority of the articles werenews articles (n = 32), with the remaining four being opinion pieces. Of these four, two sup-ported the vaccination policy, one was against, and one was neutral.From these 36 articles (S1 Table), we analyzed 1163 comments from 648 individuals (1.8comments/person). The majority (900/1163) of comments came from national news sites.Most newspapers moderated the comment section, but only 20/1163 comments were removedby moderators pre-analysis. Of the 648 individuals, 182 (28%) expressed positive perceptionsof influenza vaccines (1.7 comments/individual), 313 (48%) expressed negative perceptions(1.8 comments/individual), 25 (4%) had mixed feelings (1.3 comments/individual), and 128(20%) were neutral (2.0 comments/individual).Perceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 4 / 12Eighty-three individuals (13%) cited personal stories in their comments, 70 (11%) self-iden-tified as healthcare workers, 144 (22%) supported a condition of service influenza vaccine poli-cy like the one proposed in BC, 69 (11%) were neutral to such a policy, and 435 (67%) wereagainst such a policy (Table 1). A total of 163 (25%) users provided links to informationsources or statistics in their comments. The most commonly cited sources are noted in the S1Fig. The proportion of comments and individuals expressing the different sentiments were notsubstantially different between the entire dataset and the subgroups examined, with the excep-tion of users who provided a link or statistic in their comment. These users had a higher rate ofnegative sentiment toward the influenza vaccine than the other groups (68% vs 45%-51%) (S2Table). Of the newspapers analyzed, only the Globe and Mail and National Post publish theironline readership demographic data. Analysis of the themes by individual newspapers (Globeand Mail, National Post, CBC, CTV, BC local papers) did not show them to be substantiallydifferent from the themes that emerged from the data as a whole (Table 1).Perceptions of Influenza Vaccine and Condition of Service for HCWMost individuals fell into the following three categories: 1) those who did not believe in the ef-fectiveness of seasonal influenza vaccines and did not support vaccination as a condition of ser-vice for HCWs (48%); 2) those who did believe in the effectiveness of seasonal influenzavaccines and did support vaccination as a condition of service for HCWs (22%); and 3) thosewho did believe in the effectiveness of seasonal influenza vaccines, but did not support vaccina-tion as a condition of service for HCWs (6%). The remaining 24% of commenters did not ex-press an opinion on the effectiveness of the seasonal influenza vaccine.The distribution of commenter sentiment of the most frequent themes is shown in Fig 2.Freedom of choice. The most common theme (286 comments) was freedom of choice.Many commenters incorrectly perceived the BC policy as making influenza vaccination man-datory for HCWs, viewing it as a state intrusion into private lives and an erosion of civil liber-ties. Others agreed with the intent of the policy but thought the (incorrectly perceived) lack ofchoice would be seen as excessive, while some felt it was justified on the grounds of patient safe-ty. Of commenters who understood that the policy allowed for mask-wearing as an alternativeto the vaccine, some felt this to be fair, while others argued that the option of wearing a maskduring influenza season was designed to identify and intimidate HCWs who did not receivethe vaccine. Commenters also questioned the effectiveness of masks at preventing influenzaTable 1. Comparison of sentiment towards influenza vaccine and indicators of interest between commenters to articles in B.C. papers and nation-al papers.Number of individuals (%)(Overall)Number of individuals (%)(B.C.)Number of individuals (%)(Canada)N 648 92 556Sentiment toward influenzavaccinePositive 182 (28%) 19 (29%) 163 (29%)Negative 313 (48%) 41 (45%) 272 (49%)Neutral 128 (20%) 27 (29%) 101 (18%)Mixed 25 (4%) 5 (5%) 20 (4%)Indicator of interest HCW 70 (11%) 11 (12%) 59 (11%)Personal Story 83 (13%) 10 (11%) 73 (13%)Link or Statistic 114 (18%) 22 (24%) 92 (17%)Support for B.C.Policy144 (22%) 16 (17%) 128 (23%)doi:10.1371/journal.pone.0129993.t001Perceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 5 / 12transmission as well as the ability of HCWs to tolerate wearing masks for the duration of theirshifts.“I agree it is a good idea for healthcare workers to get vaccinated. However people havefought a long time for the right to decide what happens to their own body, this is not your [em-ployer’s] choice. Where does it stop if we give our employer these [rights] to our bodies?Women must have tubes tied after 1 child otherwise they are away from work too long if theyhave more children? Or maybe hospital workers must have [tattoos] to explain their entiremedical history to comfort patients. Same argument. Your body your choice.” “Dr. Grand”, inresponse to http://www.cbc.ca/news/canada/thunder-bay/story/2013/01/30/tby-hospital-flu-shot-debate-thunderbay.html.Vaccine effectiveness. The second most common theme (221 comments) was vaccine ef-fectiveness, with many commenters questioning the effectiveness of influenza vaccines. Somecommenters rejected the concept of immunization in general, while many supported vaccinesfor other infectious diseases such as polio, measles, mumps, rubella, and smallpox. Those whodiscussed vaccine effectiveness frequently referred to sources such as the Cochrane Collabora-tion and the University of Minnesota Centre for Infectious Disease Research and Policy(CIDRAP). A smaller group of commenters believed that seasonal influenza vaccines are effec-tive in preventing influenza and its spread. Commenters questioned the credibility of sourcesthat others on the online boards had used to support their claims. Allegations of bias in sourceswere frequent, and some commenters stated that more information and research on influenzavaccines was needed.Fig 2. Sevenmost frequent themes and their distribution of sentiment. Freedom of choice, vaccine effectiveness, patient safety, distrust of thepharmaceutical industry, distrust of the government or public health, alternatives to vaccine, and concerns about side effects are the seven most frequently-appearing themes in our analysis.doi:10.1371/journal.pone.0129993.g002Perceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 6 / 12“Get the shot, wear a mask, or go home. You are working with sick people, many with com-promised immune systems. The shot takes only a moment, and you're done. If you have aproblem with needles, perhaps you shouldn't be in mainstream public healthcare. It's not dra-conian, only a responsible reaction on the part of the hospital administration.” “Dendrast”, inresponse to http://www.cbc.ca/news/canada/thunder-bay/story/2013/01/30/tby-hospital-flu-shot-debate-thunderbay.html.“As an RN I am offended by comments that suggest refusing the shot translates to a crappynurse. Until peer reviewed research confirms I am a risk to patients, I will NOT get the shotand I am happy to stay home without pay. What other profession demands the worker toknowingly chemically alter their body with potentially insidious risks? Anyone care to knowhow the "shot" is made? Based on predictions they throw a cocktail together. EVERY year theyhave missed the mark, yet they still bully workers into having it. For you know-it-all, believe ev-erything you hear people, I remind you of one of thousands of medical blunders. the thalido-mide tragedy—a "wonder drug" endorsed by physicians, encouraged by health authorities andpermitted to kill and deform babies for 10 years before discontinued. The drug was developedand used in Nazi prison camps and fed to Canadians post war. Minus the prison camp—isthere a difference in the mandatory imposition of these two drugs?” “RNnotPOW”, in responseto http://news.nationalpost.com/2013/01/24/nurses-aide-sent-home-for-refusing-flu-shot-the-latest-healthcare-worker-suspended-in-push-to-make-immunization-mandatory/.Patient safety and social responsibility. Many commenters (173 comments) advocatedfor mandatory influenza vaccination on the basis of patient safety and social responsibility.They argued that regardless of the benefit to the person receiving the vaccine, strengtheningherd immunity against the influenza in hospitals and long-term care facilities indirectly pro-tects patients with less robust immune systems. These commenters felt that there was a duty toreduce risk to vulnerable patients. Critics replied that HCWs were only a subset of those insidea hospital at any given time, and that herd immunity is impossible given the presence of newpatients or visitors with influenza.Distrust of authorities. Many commenters (270 comments) expressed a distrust of au-thorities, including government, public health, and pharmaceutical companies. Some commen-ters speculated on whether the government would receive kickbacks from the pharmaceuticalcompanies, since the vaccine is required annually and enacting a mandatory policy would guar-antee a certain number of orders each year. Others suspected the policy was put in place not toreduce risk to patients but to reduce sick time for HCWs, thereby saving money. Several com-menters saw HCWs as role models and questioned their low rates of influenza vaccination. Fi-nally, a small number of commenters distrusted the quality of watchdog activities andinspections undertaken by Health Canada to ensure vaccine safety and effectiveness. Commen-ters about the pharmaceutical companies’ role in the issue were universally negative, with senti-ments ranging from resignation to outright accusations of deliberately endangering the publicfor profit. Some commenters believed that pharmaceutical companies’ refusal to offer compen-sation for adverse drug reactions in Canada was suspicious, given that compensation was of-fered in several other countries.Alternatives to vaccination. Many commenters (104 comments) advocated non-vaccinerelated methods of reducing risk of influenza. These alternatives to vaccination included physi-cal barriers to transmission (e.g., masks), improved hygiene (e.g., proper hand-washing by hos-pital staff), social distancing (e.g., staying home when sick), and constitutional fortification(e.g., better nutrition, vitamin C, regular exercise). Some commenters suggested these alterna-tives as a supplement to vaccination, while others denounced vaccines completely and advocat-ed only these alternatives.Perceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 7 / 12Vaccine safety. Several commenters (89 comments) had concerns about the safety of vac-cines. Some felt all vaccines were unsafe, fearing the effects of vaccine ingredients such as thi-merosal and formaldehyde. Many expressed concerns about immune reactions, from rashesand allergies to Guillain-Barré Syndrome, and some believed, or told personal stories of the in-fluenza vaccine itself transmitting influenza. Several commenters cited an article by a BC re-searcher (Skowronski et al.) that suggested that receipt of the 2008–09 seasonal influenzavaccine made patients more vulnerable to the 2009 H1N1 pandemic influenza virus [26].Influenza is a minor illness. A small number of commenters (< 30 comments) believedthat influenza was a minor illness, and vaccination as a condition of service would result inover-vaccination and a dependence on drugs and vaccines. Most of these individuals agreedthat the vaccine was necessary for specific vulnerable populations, such as patients with com-promised immune systems.Some commenters questioned the effectiveness of mandatory vaccination for just a segmentof the population, given community transmission of influenza. They debated the value of vacci-nation as a condition of service for HCWs only given that HCWs are exposed to influenza inother non-healthcare settings.DiscussionThe “influenza vaccine or mask” condition of service policy for HCWs implemented by the BCMinistry of Health in August 2012 generated reader comments to many Canadian online newsarticles. The main themes of these reader comments included: (i) freedom of choice, (ii) vac-cine effectiveness, (iii) patient safety and social responsibility, (iv) distrust of government, pub-lic health, and pharmaceutical companies, (v) alternatives to vaccines, (vi) and concerns aboutvaccine safety. The majority of the commenters did not support the BC condition of servicepolicy, and a plurality of commenters harboured a negative view of influenza vaccines.In this study, approximately 48% of individuals did not believe in the effectiveness of influ-enza vaccination and did not support the condition of service policy, while only 22% of individ-uals both believed in the effectiveness of the vaccine and supported the condition of servicepolicy. This suggests that the overall perception of the influenza vaccine and support for man-datory influenza immunization was poor among those readers who provided comments. Thisis not surprising given that many studies have also documented negative attitudes towards in-fluenza vaccines among HCWs and the general population [27–29]. Commonly cited reasonsfor refusal of the vaccine include misconceptions regarding the effectiveness and safety of thevaccine, as well as a belief that the vaccine is unnecessary because influenza is not a serious ill-ness [30–33].While we anticipated that there would be strong negative sentiment against both influenzavaccines and the BC policy, we were surprised by just how vocal this group was. We were alsosurprised by the subset of commenters who had positive sentiment toward the influenza vac-cine but did not support the BC policy. We did not see much discussion about influenza beinga minor illness. This may be because the BC policy aroused stronger emotions about labour re-lations and thus shifted the discussion in that direction and away from influenza itself. Many ofthe negative comments we found appear to be rooted in misunderstanding the influenza vac-cine and the condition of service policy. This is particularly important because comments havebeen shown to influence other readers’ perception of the issue, such that a glut of negative com-ments on an article may sway a previously neutral reader’s opinions [17–19]. Commonlysourced journal articles are often split in their recommendations about whether future effortsof public health should be focused on increasing influenza vaccine coverage or developing amore efficacious vaccine [34–36]. Some commenters have illogically but loudly used this asPerceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 8 / 12evidence that the influenza vaccine is not effective. Some research has also suggested that on-line forums are a popular outlet for negative sentiments to proliferate and that these stories aremore frequently shared than positive ones in social media [37]. Real-time responses to negativecomments could have a role in slowing the propagation of erroneous ideas about future publichealth announcements.For many commenters, the belief that influenza vaccines are ineffective is linked to a distrustof the government, public health, and pharmaceutical companies. Many users believe, even ifthey have positive sentiments towards influenza vaccines and support the BC policy, that thegovernment or public health officials have inappropriate ties with the pharmaceutical industry.A previous study that examined public perceptions of measles using a similar methodologyalso found a strong distrust with these bodies [38], suggesting that this is not solely an issue ofinfluenza vaccines but a broader topic about vaccines and government-industry relations ingeneral. Therefore, in the initial public health messaging of similar future policies, healthcareorganizations should be clear about the relationship between government and the pharmaceu-tical industry to counter public mistrust. Studies of attitudes of both HCWs who worked at or-ganizations with mandatory vaccination or alternative programs (such as mandatory vaccineor mask policies) and those who worked at organizations with voluntary programs reflect simi-lar themes [39–41].LimitationsThe major limitation of this study is that the online commenting population does not necessar-ily reflect the readership of each news source, nor of the general population. Individuals whoare most likely to comment are those with particularly strong (and often negative) opinions[23]. Further, although we treated each unique username as a unique person, it was possiblethat the same person may have used different usernames on different news sites, or even thatpersons were creating, and posting under, multiple accounts on the same news site to bolsterthe perceived support of a particular viewpoint. Finally, although we attempted to be compre-hensive in our search, because we only included sites that allowed comments we missed somemedia sources, particularly smaller local news sites without reader comments. However, thesetypes of sites would most likely have generated a small volume of comments based on the read-ership size. This biases the results towards articles on larger media sources that allow com-menting. We used online newspaper articles’ comments as our sole source of public perceptiondata. Future studies could consider other social media such as Facebook, Twitter, and blogs toconfirm findings. Finally, our study was conducted in 2013, reflecting opinions prior to the pol-icy being upheld in court, and therefore may not reflect current opinions. We only searchedEnglish-language articles, and given BC’s large East Asian and South Asian populations, this isa limitation on the generalizability of these results. This topic has not been addressed by theFrench-language media in Quebec and BC does not have a large Francophone population.ConclusionOur study identified a variety of themes in the public perception of the 2012 BC HCW condi-tion of service influenza vaccine policy. The majority of comments did not support the policy,and a plurality of comments contained negative sentiment towards influenza vaccines. Therewas alarm over the perceived lack of freedom of choice in the policy, and concern about vaccineeffectiveness and the perceived lack of transparency in the relationship between governmentand industry. However, it was also recognized that patient safety is an important part of theconversation. These findings indicated key areas of public communication that need to be ad-dressed by health or government officials as they implement similar HCW vaccinationPerceptions of Mandatory Influenza Vaccination of HealthcareWorkersPLOS ONE | DOI:10.1371/journal.pone.0129993 June 18, 2015 9 / 12strategies. They also suggest the potential need for efforts at counter-messaging on online com-ment boards or on social media. Such communication efforts by health or government officialsshould emphasize the following: 1) the choice given in such policies; 2) the science behind thedecision, such as the effectiveness and safety of influenza vaccines, particularly in the health-care setting; 3) benefits of the policy such as improved patient and worker safety; and 4) thelimits on public health interactions with the pharmaceutical industry and how this is enforced.A future study looking at comments on articles about the BC policy post-implementation mayreveal if attitudes among commenters have shifted.Supporting InformationS1 Fig. Number of times a source is cited (if n>1), divided by sentiment. Cochrane Collabo-ration reports and a Center for Infectious Disease Research and Policy report were the twomost cited sources of information in the comments.(PDF)S1 Table. Eligible Canadian news articles.(PDF)S2 Table. Source Comments. Raw data of the 1163 comments and 648 users with prelimi-nary stats.(XLSX)AcknowledgmentsPCIRN Program Delivery and Evaluation Group members are: Julie Bettinger, David Bucker-idge, Natasha Crowcroft, Shelley Deeks, Michael Finkelstein, Maryse Guay, Jemila Hamid, JeffKwong, Allison McGeer, Jennifer Pereira, Susan Quach, Sherman Quan, and Margaret Russell.Author ContributionsConceived and designed the experiments: JCK JAP SQ. Performed the experiments: YL JAPSQ. Analyzed the data: YL JAP SQ. Wrote the paper: YL JAP SQ JAB JCK KC GG YF MG.References1. Centers for Disease Control and Prevention (CDC). Prevention and control of seasonal influenza withvaccines. Recommendations of the Advisory Committee on Immunization Practices—United States,2013–2014. MMWRRecommRep. 2013; 62(RR-07): 1–43. PMID: 240482142. ThompsonWW, Comanor L, Shay DK. Epidemiology of seasonal influenza: use of surveillance dataand statistical models to estimate the burden of disease. 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