SCarrots and Sticks: Influenza Vaccination of Healthcare Workers

1
SCarrots and SticksInfluenza Vaccination of
Healthcare Workers

• Susan E Coffin, MD, MPH
• Childrens Hospital of Philadelphia
• July, 2011

2
Overview

• Rationale behind HCW influenza vaccination
• Implementing a mandatory flu vaccination program
  at CHOP
• Impact of mandate
• HCW attitudes
• Nosocomial influenza rates

3
HCW Flu Vaccination background

• Vaccination of health care workers (HCW)
  decreases
• Healthcare-associated influenza infection
• HCW absenteeism
• Secondary infections among HCWs household
  contacts
• Especially important in pediatric centers
• Large reservoir of disease in pediatric hospitals
• Large proportion of hospitalized children at high
  risk of severe influenza
• Growing interest in potential role of mandates
• Recommended by the CDC and endorsed by IDSA,
  SHEA, AAP
• Mandates successfully implemented at several
  other U.S. health systems

4
Nosocomial Influenza at CHOP (2000-2006)
5
Complications experienced by 56 patients with
nosocomial influenza
Number ()
Death 2 (3.6)
Respiratory failure 3 (5.4)
Suspected bacterial pneumonia 12 (21.4)
Bacteremia 1 (1.8)
2000-2004 complications determined by detailed
chart review Coffin, ICHE, 2009.
6
Preventing nosocomial influenza why is HCW
vaccination critical?

• Virus primarily transmitted by large respiratory
  droplets
• Less benefit from hand hygiene
• Virus can be shed 24 hrs before symptom onset
• Adults can have asymptomatic infections
• 20-50 of infected HCW were asymptomatic
• Many hospitalized pediatric patients too young to
  receive vaccine or unable to mount protective
  immune response

7
Vaccination reduces the rate of nosocomial
influenza

• Observational study at University of Virginia
  hospital
• Over 13 seasons
• Increasing vaccination rate among HCW associated
  with reduced proportion of nosocomial influenza
  (32 in 1987-88 to 3 in 1998 -99)

Salgado, ICHE, 2004
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Direct Benefits of HCW Vaccination
Talbot, ICHE, 2005
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Improving HCW Vaccination RatesStrategies that
work

• Education
• Risks of disease1,2
• Vaccine safety and efficacy2
• Internal marketing1,3
• Improving access to vaccine
• Mobile carts1,2
• Walk-in clinics, after-hours clinics2
• Expanding responsibility
• Vaccine deputies1
• Charge nurses as educators2

1) Bryant, ICHE 2004 2) Tapiainen ICHE 2005 3)
Spillman, 40th National Immunization Conference
Atlanta, March 2006
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Cognitive Dissonance 101
Flu is bad for me and my patients.
I will get vaccinated.
Flu vaccine is unsafe.
Employer Get Vaccinated!
?????
I dont get flu.
Flu vaccine doesnt work.
I dont get flu vaccine.
You Cant Make Me!!!
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Wake Forest Declination Form (2005)

• I realize I am eligible for the flu shot and
  that my refusal of it may put patients, visitors,
  and family with whom I have contact, at risk
  should I contract the flu. Regardless . . .
• Adoption was associated with doubling of
  immunization rates (35 to 70 over 4 yr period)
• Spillman SS presented at 40th National
  Immunization Conference Atlanta, March 2006

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Are Declination Forms Enough?

• CON

• PRO

• HCW vaccination no longer a passive decision
• Provides final opportunity to frame issue
• Creates focus on individual accountability

• Signals acceptance of non-vaccination
• Polarizing effect reported by some

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What level of HCW vaccination is ideal?

• Likely related to proportion of vaccinated staff
  and patients
• Retrospective study of 301 nursing homes
  (2004-2005)
• Combined immunization rate of staff and residents
  inversely associated with risk of outbreak
• 60 reduced risk of outbreak associated with
  staff immunization rates of 55 and resident
  immunization rates of 89 (OR 0.41 95 CI 0.19,
  0.89)

Shugarman, J Am Med Dir Assoc, 2006
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Implementing Mandatory Influenza Vaccine at CHOP
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2004-2005 2005-2006 2006-2007 2007-2008 2007-2008 2007-2008 2007-2008 2008-2009 2009-2010
57 69 73 90 90 90 90 92 99.6
Targeted group(s) Direct care providers in high risk settings
Targeted group(s) All direct care providers All direct care providers All direct care providers All direct care providers All direct care providers All direct care providers All direct care providers
Targeted group(s) All who work in building where patient care is delivered
Education and Communication Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum Mandatory education module included in fall core curriculum
Education and Communication Linked to pandemic flu preparedness Linked to pandemic flu preparedness Linked to pandemic flu preparedness Linked to pandemic flu preparedness Linked to pandemic flu preparedness Linked to pandemic flu preparedness Linked to pandemic flu preparedness Linked to pandemic flu preparedness
Education and Communication Linked to patient safety Linked to patient safety Linked to patient safety Linked to patient safety Linked to patient safety Linked to patient safety Linked to patient safety Linked to patient safety
Education and Communication Remedial education Remedial education
Education and Communication Town hall meetings
Logistics Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours Expanded Occupational Health clinic hours
Logistics Unit- and practice-based flu captains Unit- and practice-based flu captains Unit- and practice-based flu captains Unit- and practice-based flu captains Unit- and practice-based flu captains Unit- and practice-based flu captains Unit- and practice-based flu captains Unit- and practice-based flu captains
Logistics Flu vaccine clinics held at meetings Flu vaccine clinics held at meetings Flu vaccine clinics held at meetings Flu vaccine clinics held at meetings Flu vaccine clinics held at meetings Flu vaccine clinics held at meetings Flu vaccine clinics held at meetings Flu vaccine clinics held at meetings
Logistics Roving vaccination carts Roving vaccination carts Roving vaccination carts Roving vaccination carts Roving vaccination carts Roving vaccination carts Roving vaccination carts Roving vaccination carts
Declination Form None None
Declination Form Voluntary Voluntary Voluntary
Declination Form Mandatory Mandatory Mandatory Mandatory
Administrative Senior administration stresses importance of flu vaccination to clinical leaders Senior administration stresses importance of flu vaccination to clinical leaders Senior administration stresses importance of flu vaccination to clinical leaders Senior administration stresses importance of flu vaccination to clinical leaders Senior administration stresses importance of flu vaccination to clinical leaders Senior administration stresses importance of flu vaccination to clinical leaders Senior administration stresses importance of flu vaccination to clinical leaders Senior administration stresses importance of flu vaccination to clinical leaders
Administrative Biweekly compliance reports_at_ Biweekly compliance reports_at_ Biweekly compliance reports_at_
Administrative Weekly compliance reports_at_
Use of LAIV Offered to providers who did not work in high risk setting
Use of LAIV Offered to all providers except those who worked on oncology unit Offered to all providers except those who worked on oncology unit Offered to all providers except those who worked on oncology unit Offered to all providers except those who worked on oncology unit Offered to all providers except those who worked on oncology unit Offered to all providers except those who worked on oncology unit Offered to all providers except those who worked on oncology unit Offered to all providers except those who worked on oncology unit
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Why CHOP HCW decline flu vaccine
2005-2006 2006-2007
Allergy/Reaction 39 26
Recd vaccine elsewhere 36 6
Concern about side effects 34 193
Never get flu 9 27
Personal choice 119 53
Religious 1 0
Other 32 15
Pregnancy 11 5
Fear of needles 7 0
TOTAL 276 392
17
Vaccination of physicians
2007-2008 2008-2009
53 MD groups gt80 (19/36) 22 MD groups fully
vaccinated (8/36) 81 of MDs vaccinated
(623/777)
16 MD groups gt80 (5/31)
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2009-2010 CHOP Employee Influenza Vaccine
Program

• July, 2009 The CHOP Patient Safety Committee
  recommends mandatory annual influenza vaccine for
  all staff working in buildings where patient
  care was provided or whom provide patient care.
• includes clinicians, support staff, volunteers,
  students vendors informed of policy and asked to
  ensure compliance.

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Key Strategies, 2009-2010

• PROGRAM ELEMENTS
• Create accurate list of targeted staff and assure
  ability to provide timely, accurate reports
• Establish method for evaluating requests for
  medical and religious exemptions
• Determine timeline and educate

20
Program Timeline, 2009-2010

• PLAN
• 6 week program (9/15-10/31/09)
• 2 week furlough for staff unvaccinated and
  without exemption as of 11/1/09
• Termination if unvaccinated and without an
  exemption as of 11/15/09
• REALITY
• 2 week extension due to delays in receipt of
  seasonal flu vaccine

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What happened 2009-2010

• gt9000 HCW vaccinated
• 50 persons established medical exemptions
• 2 persons established religious exemptions
• 145 received temporary suspension
• 9 persons terminated

22
Labor Relations 101

• 2 meetings to negotiate
• Impasse declared

23
Quotes from 10/26/09 negotiation

• Youre not making sure everyone who comes into
  CHOP is vaccinated.
• Why cant we just wear masks all winter?
• No other institutions or regulatory groups
  support this.
• This discriminates against employees who have
  less access to educational resources on the
  internet.

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Labor Relations 102

• Grievance filled (November, 2010)
• CHOP Termination for just cause
• Behaviors that are detrimental to the
  institution
• insubordination
• Union Breech of contract
• Not included in negotiated contract

25
Findings and Opinions from Arbitration

• There can be no doubt that the Hospital had the
  right to promulgate a reasonable rule/condition
  of employment that would better ensure the health
  and safety of CHOPs patient population.
• It is this Arbitrators finding that the policy
  implemented by the Hospital was reasonable in the
  context of the Hospitals young, vulnerable
  patient community.

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Year 2 Experience 2010-2011

• gt9500 HCW vaccinated
• Request for medical exemptions by 7 HCW (all
  granted)
• Request for religious exemptions by 3 HCW
• Review by retired judge
• 2 granted, 1 denied
• No suspensions or terminations.

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Impact of a Vaccine Mandate
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Evaluating Impact of Vaccine Mandate

• METHODS
• Cross-sectional study of a random sample of HCW
  subjected to the mandate
• Anonymous 20 item questionnaire adapted from
  validated previously published instrument
  (electronicgtgtpaper distribution)

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Study QuestionWhat predicts agreement with the
mandate?

• Primary outcome attitude towards influenza
  vaccine mandate
• Do you agree with CHOPs policy that requires
  all health care workers to receive annual flu
  vaccination (a flu shot or the nasal spray
  vaccine) unless there is a medical or religious
  contraindication

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Results Survey

• Response rate (58)
• 1,388 respondents (total distributed 2,443)
• 657 (47) clinical
• 731 (74) nonclinical
• Respondent characteristics
• 77 female
• 65 lt 45 years of age
• 68 have worked at CHOP lt10 years
• 90 staff previously vaccinated
• 91 felt they had received info they needed from
  CHOP to make decision about flu vaccination

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Results Reasons for vaccination

• Of those who had been vaccinated in past,
  majority of respondents cited
• Protection of self, family and patients
• Job responsibility
• Education received at work
• Of those who declined flu vaccination in past,
  majority of respondents cited
• Not being at high risk
• Fear of side effects
• Belief that vaccine is not effective

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Results Agreement with mandate

• 77 respondents intended to be vaccinated before
  hearing about the mandate
• 75 reported agreeing with mandate
• 23 of respondents strongly considered declining
  the flu vaccine after hearing about the mandate
• 72 reported agreeing that the mandate is
  coercive but almost everyone (96) also agreed
  that mandatory policies are important for
  protecting patients

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Results Agreement with mandate

• 75 of both clinicians and non-clinicians agree
  that societal rights outweigh individual rights
  when it comes to vaccination
• 95 of both groups agree that parents have an
  obligation to make sure their children receive
  recommended vaccines
• gt95 of both groups agree with policies for
  requiring vaccination or screening for TB, HepB,
  measles, rubella and varicella

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Predictors of Agreement with Mandate

• Demographic Predictors

• Attitudinal Predictors

• Contact with high risk individuals at home or at
  work
• Age
• Amount of time working at CHOP
• Gender
• Previous receipt of flu vaccine
• Previous experience with flu vaccine

• Reasons for previous flu vaccine receipt
• Reasons for previous flu vaccine declination
• Attitudes towards influenza prevention
• Intention to receive the vaccine before knowledge
  of the mandate
• Attitudes towards other mandatory vaccination
  programs
• Attitudes towards vaccines in general

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Factors associated with Agreement with Mandate
unadjusted results
Unadjusted OR (95 C.I.)
Clinical (vs. Non-clinical) 1.49 (1.32, 1.68)
Previous vaccination Yes (vs No) 6.3 (5.10, 7.79)
Intention to be vaccinated before mandate, Yes (vs No) 10.6 (9.1, 12.5)
Belief in Mandate benefits 29.0 (24.3, 34.6)
Support other employment mandates 4.02 (3.36, 4.80)
Ethical beliefs regarding vaccines / public health 6.87 (6.00, 7.86)
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Factors associated with Agreement with Mandate
multivariable model
Unadjusted OR (95 C.I.) Adjusted OR (95 C.I.)
Clinical (vs. Non-clinical) 1.49 (1.32, 1.68) 1.08 (0.94, 1.26)
Previous vaccination Yes (vs No) 6.3 (5.10, 7.79) 1.68 (1.29, 2.19)
Intention to be vaccinated before mandate, Yes (vs No) 10.6 (9.1, 12.5) 2.64 (2.17, 3.21)
Belief in Mandate benefits 29.0 (24.3, 34.6) 14.08 (11.5, 17.2)
Support other employment mandates 4.02 (3.36, 4.80) 1.40 (1.13, 1.73)
Ethical beliefs regarding vaccines / public health 6.87 (6.00, 7.86) 3.15 (2.70, 3.70)
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Possible Implications

• Majority report that mandate is coercive
• Does not appear to affect agreement with mandate
• Factors associated with agreement with mandate
  represent attitudes and beliefs that may be
  modifiable through targeted outreach and
  educational activities
• May need to focus upon different key themes for
  clinical and non-clinical staff
• Reasons for previous declination of vaccination
  show that misconceptions regarding risk for
  infection and vaccine safety and efficacy do
  persist
• Educational modalities may not be effectively
  communicating key messages

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Do Mandates Improve Patient Outcomes?
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Summary

• Nosocomial influenza poses a serious threat to
  hospitalized children.
• HCW vaccination rates can be substantially
  improved through implementation of various
  voluntary measures.
• Mandates may be required to achieve maximal
  levels of HCW compliance but many HCW may support
  mandates and believe that they are important way
  to protect patients and staff
• Attitudes and beliefs associated with support of
  mandate may transcend professional role

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Questions?
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Acknowledgements

• Occupational Health
• - Mary Cooney
• Infection Prevention and Control
• - Keith St. John
• - Eileen Sherman
• Infectious Diseases Epidemiology Research Group
• - Kristen Feemster
• - Priya Prasad
• All CHOP Healthcare Workers