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Electronic Nudges to Increase Influenza Vaccination in Immunosuppressed Adults Across the Age Spectrum: A Pooled Analysis of 2 Nationwide Randomized Trials.

Anne Marie Reimer Jensen·Niklas Dyrby Johansen·Peter Suldrup Wolff·Muthiah Vaduganathan·Ankeet S Bhatt·Daniel Modin·Kristoffer Grundtvig Skaarup·Lisa Steen Duus·Safia Chatur·Brian L Claggett·Kira Hyldekær Janstrup·Joshua A Hill·Harriette G C Van Spall·Carsten Schade Larsen·Lykke Larsen·Lothar Wiese·Michael Dalager-Pedersen·Lars Køber·Scott D Solomon·Pradeesh Sivapalan·Jens Ulrik Stæhr Jensen·Cyril Jean-Marie Martel·Tyra Grove Krause·Tor Biering-Sørensen
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Abstract

BACKGROUND: Immunosuppressed individuals face higher risk of severe influenza complications, yet vaccination coverage remains low. We aimed to assess the effect of electronic letter-based nudges on influenza vaccination uptake by immunosuppression status. METHODS: We performed a participant-level pooled analysis of 2 methodologically harmonized, nationwide, pragmatic randomized clinical trials during the 2023-2024 influenza season. Adults aged &#x2265;65 years (NUDGE-FLU-2) and adults aged 18-64 years with chronic conditions (NUDGE-FLU-CHRONIC) were included, with immunosuppression defined by an immunosuppressive diagnosis or a filled prescription for immunosuppressive therapy. Participants were randomized in a 2.45:1:1:1:1:1:1 ratio to usual care or 1 of 6 electronic letter interventions. The primary outcome was receipt of influenza vaccination by 1 January 2024 ascertained from nationwide administrative health registries. Effect modification by immunosuppression status was assessed using binomial regression. RESULTS: Among 1 181 254 participants (mean age 67 years; 73 830 [6.3%] immunosuppressed), 66.1% were vaccinated. Any letter increased vaccine uptake compared with usual care (absolute difference, 2.79% points; 95% confidence interval [CI], 2.60-2.98; P < .001), with greater effect among immunosuppressed individuals (+4.12 vs +2.70% points; Pinteraction = .002). In younger adults with chronic conditions, letter-based nudges increased vaccination rates by 11.7% points overall and by 13.3% points among those with immunosuppression (Pinteraction = .007). Among immunosuppressed individuals, nudging effects appeared greater for those with immunosuppressive conditions than for those receiving immunosuppressive treatment. CONCLUSIONS: Electronic letter-based nudges increased influenza vaccination rates, with greater benefit among immunosuppressed individuals. These findings support implementation of low-cost, letter-based nudging strategies to improve vaccine uptake in this high-risk population. Clinical Trials Registration. NCT06030726 and NCT06030739.

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AdolescentAdultAgedFemaleHumansMaleMiddle AgedYoung AdultAdherence InterventionsImmunocompromised HostInfluenza VaccinesInfluenza, HumanRandomized Controlled Trials as TopicVaccinationbehavioral nudgesimmunosuppressioninfluenza vaccinationpragmatic randomized trialsvaccine uptakeJournal ArticleMeta-AnalysisResearch Support, Non-U.S. Gov't

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Anne Marie Reimer Jensen, Niklas Dyrby Johansen, Peter Suldrup Wolff, Muthiah Vaduganathan, Ankeet S Bhatt, Daniel Modin, Kristoffer Grundtvig Skaarup, Lisa Steen Duus, Safia Chatur, Brian L Claggett, Kira Hyldek&#xe6;r Janstrup, Joshua A Hill, Harriette G C Van Spall, Carsten Schade Larsen, Lykke Larsen, Lothar Wiese, Michael Dalager-Pedersen, Lars K&#xf8;ber, Scott D Solomon, Pradeesh Sivapalan, Jens Ulrik St&#xe6;hr Jensen, Cyril Jean-Marie Martel, Tyra Grove Krause, Tor Biering-S&#xf8;rensen. 2026-09-02. Electronic Nudges to Increase Influenza Vaccination in Immunosuppressed Adults Across the Age Spectrum: A Pooled Analysis of 2 Nationwide Randomized Trials.. https://doi.org/10.1093/cid%2Fciag219

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