Influenza Vaccination of Healthcare Personnel: Disease, Vaccine, Beliefs, Barriers, and Recommended

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Influenza Vaccination of Health-care
PersonnelDisease, Vaccine, Beliefs,
Barriers,and Recommended Strategies to Improve
VaccinationAdapted from presentations by Gina
T. Mootrey, DO, MPH and William Atkinson, MD,
MPH, Centers for Disease Control and Prevention
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HHS Initiative for Influenza Vaccination of
Health Care Personnel Components

• Two components
• Improving HHS health care employee influenza
  vaccination, with focus on
• Federal Occupational Health
• Indian Health Service
• U.S. Public Health Service Commissioned Officers
• NIH Clinical Center
• CDC
• Promoting influenza vaccination to non-federal
  health care organizations and HCP

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HHS Initiative for Influenza Vaccination of
Health Care Personnel HHS Employees

• Three focus areas
• Developing office and agency specific strategies
  to improve HCP vaccination levels
• Measuring employee vaccination rates
• Disseminating a toolkit containing
• Standard presentation
• Relevant articles
• Posters
• Fact sheets, questions and answers
• Vaccine information statements
• Links to other resources
• Toolkit will be available on HHS OPHS website

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HHS Initiative for Influenza Vaccination of
Health Care Personnel Outreach

• Potential partners include, but are not limited
  to
• American Academy of Family Physicians
• American Academy of Pediatrics
• American Association of Homes and Services for
  the Aging
• American Association for Respiratory Care
• American College of Obstetricians and
  Gynecologists
• American College of Occupational and
  Environmental Medicine
• American College of Physicians
• American Federation of Labor and Congress of
  Industrial Organizations
• American Federation of State, County, and
  Municipal Employees
• American Health Care Association
• American Hospital Association
• American Medical Association
• American Nurses Association
• American Society of Health-System Pharmacists
• Association for Professionals in Infection
  Control and Epidemiology, Inc.
• National Black Nurses Association
• National Foundation for Infectious Diseases
• National Hispanic Medical Association

HHS will also promote Influenza Vaccination of
Health Care Personnel (HCP) nationwide Healthy
People 2010 target 60 of all HHS HCP will be
vaccinated annually By 2010 HHS plans to partner
with many other organizations to promote HCP
influenza vaccination
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Influenza

• Highly infectious viral illness
• 3 pandemics in 20th century
• Estimated 21 million deaths worldwide in pandemic
  of 1918-1919
• Virus first isolated in 1933

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Influenza Pathogenesis

• Respiratory transmission of virus likely major
  route of transmission
• Replication in respiratory epithelium with
  subsequent destruction of cells
• Viremia rarely documented
• Viral shedding in respiratory secretions for 1
  day before illness and 5-10 days after illness
  onset

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Impact of Influenza-United States

• 5 to 20 of the population are infected every
  year.
• Approximately 36,000 annual influenza-associated
  deaths on average
• Persons 65 years of age and older account for
  more than 90 of deaths
• Higher mortality during seasons when influenza
  type A (H3N2) viruses predominate

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Impact of Influenza-United States

• Highest rates of complications and
  hospitalization occur among young children and
  person 65 years and older
• Average of more than 200,000 influenza-related
  excess hospitalizations annually
• 57 of hospitalizations among persons younger
  than 65 years of age
• Greater number of hospitalizations during type A
  (H3N2) epidemics

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Impact of Influenza in HCP

• In one randomized controlled trial of influenza
  vaccination of HCP, between 7.1 and 26 of
  unvaccinated HCP had documented serologic
  evidence of influenza infection in any one year.
• Of these, 42 could not recall having a febrile
  respiratory illness1

1Wilde et al., JAMA 199928190813
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Impact of Influenza Vaccination of HCP on patients

• Over 12 years in one hospital, vaccination
  coverage increased from 4 to 67
• Laboratory-confirmed influenza cases among HCP
  decreased from 42 to 9
• Nosocomial cases among hospitalized patients
  decreased 32 to 0 (plt0.0001)1
• Two randomized controlled trials evaluated impact
  of HCP influenza vaccination on residents in
  nursing homes2,3
• They estimated gt 40 decrease in overall
  mortality among residents in the setting of high
  employee vaccination levels, regardless of
  patient vaccination levels.

1Salgado et al., Inf Cont Hosp Epi 200425923-8
2Carman et al., Lancet 2000355(9198) 93--7
3Potter, et al., J Infect Dis 19971751--6
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Influenza Vaccines

• Inactivated subunit (TIV)
• intramuscular
• trivalent
• split virus and subunit types
• Yearly vaccination
• Live attenuated vaccine (LAIV)
• intranasal
• Trivalent
• Yearly vaccination

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Inactivated Influenza Vaccine Effectiveness in
Adults lt65 years

• 80 (95 CI 56 to 91) efficacious when
  vaccine matched circulating strain
• 50 (95 CI 27 to 65) when not well matched
• Jefferson, et al. Cochrane Database Syst Rev.
  2007 Apr 18(2)CD001269.

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LAIV Effectiveness in Healthy Adults

• Randomized, double-blind, placebo-controlled
  challenge study
• 92 healthy adults (LAIV, n 29 placebo, n 31
  inactivated influenza vaccine, n 32) aged
  18--41 years ne (Treanor et al., Vaccine
  199918899--906.)
• Overall efficacy of LAIV and inactivated
  influenza vaccine in preventing
  laboratory-documented influenza 85 LAIV and 71
  TIV
• Nichol et al., JAMA 199928213744, study in
  1997-98 with suboptimal vaccine-wild virus match
  no virologic-proven outcomes
• 24 fewer febrile upper respiratory illness
  episodes (URI)
• 27 fewer lost work days due to febrile URI
• 41-45 fewer days of antibiotic use

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Inactivated Influenza Vaccine Adverse Reactions

• Local reactions 15-20
• Fever, malaise not common
• Allergic reactions rare
• (Anaphylaxis lt1 in 1 million)
• Neurological rare reactions
• (Guillain-Barre Syndrome 1 in 1 million)

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Live Attenuated Influenza VaccineAdverse
Reactions in Adults

• 18-49 years adults in one clinical trial, signs
  and symptoms reported more frequently among LAIV
  recipients (n 2,548) than placebo recipients (n
  1,290) within 7 days after each dose included
• cough (14 and 11, respectively)
• runny nose (45 and 27, respectively)
• sore throat (28 and 17, respectively)
• chills (9 and 6, respectively)
• tiredness/weakness (26 and 22, respectively)

Belshe RB et al. Clin Infect Dis 200439920--7.
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Influenza Vaccination of Health-care Personnel

• Only 45.3 percent of U.S. health-care personnel
  were vaccinated in 2007

MMWR 200655 (RR-2). February 24, 2006.
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Reasons for Accepting Vaccination Among
Health-care Personnel
Christini AB, et al. Infect Control Hosp
Epidemiol 200728171-7
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Reasons for Rejecting Vaccination Among
Health-care Personnel
Vaccine needs to be made available during all
employment shifts.
Christini AB, et al. Infect Control Hosp
Epidemiol 200728171-7
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Health Care Worker Groups

• Qualitative Assessment of Factors Influencing
  Immunization of Health Care Workers, CDC,
  unpublished data
• Individual in-depth interview or focus group at
  hospitals in 4 cities (NYC, Hollywood (FL),
  Scottsdale (AZ), San Francisco, August 2007
• Results
• Professional schools were reported as a driver of
  vaccination
• Believe vaccines are a mechanism to protect
  themselves from patients, rather than as a means
  to protect patients
• Clinical workers demonstrated limited or
  inaccurate knowledge of infectious diseases and
  their routes of transmission
• Resistance to seasonal influenza vaccination was
  characterized by
• Perceptions of limited applicability to
  themselves
• Perceptions of minimal consequences from
  contracting flu
• Pronounced lack of trust in the vaccine

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Literature reviewHofman F, Ferracin C, Marsh G,
Dumas R. Infection 200534142-147

• Literature review of 32 studies performed
  1985-2002
• US, Canada, Europe
• Vaccination rates 2.1 - 82
• Ideas encouraging influenza vaccination
• To protect oneself (33-93) - strongest
  motivation
• To protect patients (2-98) -secondary motivation
• Free and convenient (11-58)
• Being previously vaccinated
• Following the example set by peers

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Literature reviewHofman F, Ferracin C, Marsh G,
Dumas R. Infection 200534142-147

• Ideas preventing influenza vaccination
• Fear of adverse events (8-54)
• Misconception that vaccination can cause
  influenza (10-45)
• Not at risk (6-58)
• Times/locations of vaccination were unsuitable
  (6-59)
• Doubt that influenza is a serious disease (2-32)
• Lack of vaccine efficacy (3-32) - except
  physicians
• Fear of injections (4-26)
• 2 main barriers
• Misperception of influenza, its risks, the role
  of HCW in its transmission to patients, and the
  importance and risks of vaccination
• Lack of (or perceived lack of ) conveniently
  available vaccine

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Common Themes

• Reasons for accepting influenza vaccination
• Protect self
• Protect patients
• Convenience
• Peer influence
• Prior experience

• Reasons for rejecting influenza vaccination
• Concerns about vaccine safety or efficacy
• Not at risk (healthy immune system)
• Lack of understanding of transmission of
  influenza
• Fear of needles
• Not convenient

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Notable Differences

• Differences in motivators, barriers and beliefs
  by
• Category of healthcare worker
• Type of institution
• Age
• Level of knowledge about influenza and vaccine
• Level of trust

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Strategies for Improving HCP Vaccination Rates

• Successful HCP vaccination programs are
  multifaceted and combine
• Education campaigns
• Role models
• Improved access
• Measurement and feedback
• Legislation and regulation
• Task Force on Community Preventive Services
  currently conducting a systematic review of
  influenza worksite vaccination

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Month of Peak Influenza Activity United States,
1976-2006
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There is usually ample time to vaccinate
HCP before influenza occurs!
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13
13
3
3
MMWR 200755(RR-6)5
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Support from Professional Groups

• American College of Physicians (ACP)3
• October 2007 - Recommendation that annual
  influenza vaccine should be required for every
  health care worker with direct patient care
  activities.
• Infectious Diseases Society of America  (IDSA)2
• January 2007- Recommendation that U.S. adopt
  policy to include mandatory annual influenza
  vaccination among healthcare workers
• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO)1
• New standard, effective 1/1/07 Influenza
  immunization offered to staff and licensed
  independent practitioners.
• National Foundation for Infectious Diseases
  (NFID)4
• Call to Action recommendations and Best Practices
  for immunizing health care personnel against
  influenza

1http//www.jcrinc.com/26813/newsletters/12882/,
accessed 11/11/07 2Pandemic
and Seasonal Influenza Principles for U.S.
Action, January 2007 3http//www.acponline.
org/college/pressroom/hcw.htm, accessed
11/13/07 4http//www.nfid.org, accessed
05/15/08.