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SCarrots and Sticks: Influenza Vaccination of Healthcare Workers

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Title: The Impact of an Influenza Vaccine Mandate for Health Care Workers at a Pediatric Multi-center Network: Preliminary Results Author: System Administrator – PowerPoint PPT presentation

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Title: SCarrots and Sticks: Influenza Vaccination of Healthcare Workers


1
SCarrots and Sticks Influenza 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
8
Direct Benefits of HCW Vaccination
Talbot, ICHE, 2005
9
Improving HCW Vaccination Rates Strategies 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
10
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!!!
11
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

12
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

13
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
14
Implementing Mandatory Influenza Vaccine at CHOP
15
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
16
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)
18
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.

19
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

21
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.

24
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.

26
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.

27
Impact of a Vaccine Mandate
28
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)

29
Study Question What 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

30
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

31
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

32
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

33
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

34
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

35
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)
36
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)
37
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

38
Do Mandates Improve Patient Outcomes?
39
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

40
Questions?
41
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
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