Child Influenza Vaccination and Adult Work Loss: Reduced Sick Leave Use Only in Adults With Paid Sick Leave

Published:December 17, 2018DOI:


      Children are a population of interest for influenza. They are at increased risk for severe influenza, comprise a substantial portion of influenza morbidity, and significantly contribute to its transmission in the household and subsequent parental work loss. The association between influenza vaccination and work loss prevention, however, has rarely been studied, and the sparse existing literature has very limited generalizability to U.S. adults, thus requiring better characterization.


      Using pooled National Health Interview Survey data (2013–2015, analyses conducted in 2018) nationally representative of working U.S. adults with household children (n=23,014), zero-inflated negative binomial regression examined the association of child influenza vaccination (exposure) with sick days (outcome) stratified by paid sick leave (no: n=10,741, yes: n=12,273).


      Child influenza vaccination was associated with significantly lower sick day usage, but only among adults with paid sick leave (prevalence rate ratio=0.79, 95% CI=0.67, 0.93), equating to average annual sick days of 4.07 vs 3.29 in adults with unvaccinated versus vaccinated household children (difference=0.78 fewer days annually).


      Influenza vaccination of children is associated with reduced sick leave in household adults, helping to keep the workforce healthy and reduce influenza's costly annual economic burden. This only occurred among adults with paid sick leave, however, which is distributed inequitably by income, education, gender, occupation, and race/ethnicity. Health in All Policies considers downstream health effects of social and economic policy; the failure of federal policy to ensure paid sick leave likely contributes to propagating influenza and health inequities.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


      1. CDC. Children, the Flu, and the Flu Vaccine. Published November 5, 2013. Accessed May 5, 2014.

        • Thompson WW
        • Shay DK
        • Weintraub E
        • et al.
        Influenza-associated hospitalizations in the United States.
        JAMA. 2004; 292: 1333-1340
        • CDC
        in: Atkinson W Wolfe C Hamborsky J Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Public Health Foundation;, Washington, DC2015: 187-208
        • Teo SSS
        • Nguyen-Van-Tam JS
        • Booy R
        Influenza burden of illness, diagnosis, treatment, and prevention: what is the evidence in children and where are the gaps?.
        Arch Dis Child. 2005; 90: 532-536
        • Fraaij PLA
        • Heikkinen T
        Seasonal influenza: the burden of disease in children.
        Vaccine. 2011; 29: 7524-7528
        • Jordan R
        • Connock M
        • Albon E
        • et al.
        Universal vaccination of children against influenza: are there indirect benefits to the community? A systematic review of the evidence.
        Vaccine. 2006; 24: 1047-1062
        • Viboud C
        • Boëlle P-Y
        • Cauchemez S
        • et al.
        Risk factors of influenza transmission in households.
        Br J Gen Pract J R Coll Gen Pract. 2004; 54: 684-689
        • Esposito S
        • Gasparini R
        • Bosis S
        • et al.
        Clinical and socio–economic impact of influenza and respiratory syncytial virus infection on healthy children and their households.
        Clin Microbiol Infect. 2005; 11: 933-936
        • Neuzil KM
        • Hohlbein C
        • Zhu Y
        Illness among schoolchildren during influenza season: effect on school absenteeism, parental absenteeism from work, and secondary illness in families.
        Arch Pediatr Adolesc Med. 2002; 156: 986
        • King JC
        • Beckett D
        • Snyder J
        • Cummings GE
        • King BS
        • Magder LS
        Direct and indirect impact of influenza vaccination of young children on school absenteeism.
        Vaccine. 2012; 30: 289-293
        • Bourgeois FT
        • Valim C
        • McAdam AJ
        • Mandl KD
        Relative impact of influenza and respiratory syncytial virus in young children.
        Pediatrics. 2009; 124: e1072-e1080
        • Antonova EN
        • Rycroft CE
        • Ambrose CS
        • Heikkinen T
        • Principi N
        Burden of paediatric influenza in Western Europe: a systematic review.
        BMC Public Health. 2012; 12: 968
        • Heikkinen T
        • Silvennoinen H
        • Peltola V
        • et al.
        Burden of influenza in children in the community.
        J Infect Dis. 2004; 190: 1369-1373
        • Palmer LA
        • Rousculp MD
        • Johnston SS
        • Mahadevia PJ
        • Nichol KL
        Effect of influenza-like illness and other wintertime respiratory illnesses on worker productivity: the child and household influenza-illness and employee function (CHIEF) study.
        Vaccine. 2010; 28: 5049-5056
        • Fiore AE
        • Uyeki TM
        • Broder K
        • et al.
        Prevention and control of influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2010.
        MMWR Recomm Rep. 2010; 59: 1-62
        • Principi N
        • Esposito S
        • Marchisio P
        • Gasparini R
        • Crovari P
        Socioeconomic impact of influenza on healthy children and their families.
        Pediatr Infect Dis J. 2003; 22: S207-S210
        • Vesikari T
        • Fleming DM
        • Aristegui JF
        • et al.
        Safety, efficacy, and effectiveness of cold-adapted influenza vaccine-trivalent against community-acquired, culture-confirmed influenza in young children attending day care.
        Pediatrics. 2006; 118: 2298-2312
        • King JC
        • Stoddard JJ
        • Gaglani M
        • et al.
        Effectiveness of school-based influenza vaccination.
        N Engl J Med. 2006; 355: 2523-2532
        • Salleras L
        • Domínguez A
        • Pumarola T
        • et al.
        Effectiveness of virosomal subunit influenza vaccine in preventing influenza-related illnesses and its social and economic consequences in children aged 3–14 years: a prospective cohort study.
        Vaccine. 2006; 24: 6638-6642
        • Jefferson T
        • Rivetti A
        • Di Pietrantonj C
        • Demicheli V
        Vaccines for preventing influenza in healthy children.
        Cochrane Database Syst Rev. 2018; 2CD004879
        • Lee BY
        • Shah M
        Prevention of influenza in healthy children.
        Expert Rev Anti Infect Ther. 2012; 10: 1139-1152
        • Fisman DN
        • Bogoch II
        Have you herd? Indirect flu vaccine effects are critically important.
        Lancet Public Health. 2017; 2: e57-e58
        • Molinari N-AM
        • Ortega-Sanchez IR
        • Messonnier ML
        • et al.
        The annual impact of seasonal influenza in the U.S.: measuring disease burden and costs.
        Vaccine. 2007; 25: 5086-5096
        • Santibanez TA
        • Grohskopf LA
        • Zhai Y
        • Kahn KE
        Complete influenza vaccination trends for children six to twenty-three months.
        Pediatrics. 2016; 137: 1-10
        • Rudolph L
        • Caplan J
        • Ben-Moshe K
        • Dillon L
        Health In All Policies: A Guide for State and Local Governments.
        American Public Health Association and Public Health Institute, Washington, DC2013
        • Clemans-Cope L
        • Kenney G
        Low income parents’ reports of communication problems with health care providers: effects of language and insurance.
        Public Health Rep. 2007; 122: 206-216
      2. Andersen R Rice TH Kominski GF Changing the U.S. Health Care System: Key Issues in Health Services Policy and Management. 3rd ed. Jossey-Bass, San Francisco2007
        • Piper K
        • Youk A
        • James AE
        • Kumar S
        Paid sick days and stay-at-home behavior for influenza.
        PLoS One. 2017; 12e0170698
        • Nettleman MD
        • White T
        • Lavoie S
        • Chafin C
        School absenteeism, parental work loss, and acceptance of childhood influenza vaccination.
        Am J Med Sci. 2001; 321: 178-180
        • Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention
        2014 National Health Interview Survey (NHIS) Public Use Data Release Survey Description.
        HHS, Hyattsville, MD2015
        • Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention
        2013 National Health Interview Survey (NHIS) Public Use Data Release Survey Description. Hyattsville.
        HHS, MD2014
        • Division of Health Interview Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention
        2015 National Health Interview Survey (NHIS) Public Use Data Release Survey Description.
        HHS, Hyattsville, MD2016
        • Korn EL
        • Graubard BI
        Analyses Using Multiple Surveys.
        In: Analysis of Health Surveys. Wiley series in probability and statistics. Wiley, New York, NY1999:: 278-303
        • Long JS
        • Freese J
        Regression Models for Categorical Dependent Variables Using Stata.
        2nd ed. StataCorp LP, College Station, TX2006
      3. UCLA: Statistical Consulting Group. Stata Data Analysis Examples: Zero-inflated Negative Binomial Regression. Published October 12, 2011. Accessed April 28, 2016.

      4. Allison PD. Listwise Deletion: It's NOT Evil. Published June 2014. Accessed April 21, 2016.

        • DeRigne L
        • Stoddard-Dare P
        • Quinn L
        Workers without paid sick leave less likely to take time off for illness or injury compared to those with paid sick leave.
        Health Aff (Millwood). 2016; 35: 520-527
        • Peipins LA
        • Soman A
        • Berkowitz Z
        • White MC
        The lack of paid sick leave as a barrier to cancer screening and medical care-seeking: results from the National Health Interview Survey.
        BMC Public Health. 2012; 12: 520
        • Potepan MJ
        Paid Sick Leave: Access, Costs and Feasibility of Implementation at the State Level.
        Sacramento State Center for California Studies, Sacramento, CA2008
        • Cordoba E
        • Aiello AE
        Social determinants of influenza illness and outbreaks in the United States.
        N C Med J. 2016; 77: 341-345
        • Susser P
        • Ziebarth NR
        Profiling the U.S. sick leave landscape: presenteeism among females.
        Health Serv Res. 2016; 51: 2305-2317
        • Bleser WK
        • Miranda PY
        • Jean-Jacques M
        Racial/ethnic disparities in influenza vaccination of chronically ill U.S. adults: the mediating role of perceived discrimination in health care.
        Med Care. 2016; 54: 570-577