1. Influenza Vaccination of Healthcare Personnel in California, 2007-2010 Tricia McLendon, MPH Healthcare-Associated Infections Program California Department of Public Health March 29, 2011

2. 2 California Influenza Vaccination Mandates for Acute Care Hospitals Free vaccine to all employees –Signed declination Report to CDPH –Vaccination of healthcare personnel –Implementation of CDC recommendations

3. 3 Overview Background Vaccination of healthcare personnel Barriers and strategies Mandatory policies Definitions California experience

4. 4 Seasonal Influenza Significant morbidity and mortality –Elderly, young children, underlying medical conditions Healthcare personnel (HCP) are important source of transmission – Work when ill –Asymptomatic infection and convalescent viral shedding Source: Pavia AT. Clin Infect Dis: 2010; 50:465-7.

5. 5 2009 Influenza A (H1N1) Symptoms similar to seasonal influenza –Hospitalization highest in children < 4 years –Mortality highest among persons 50-64 years –Illness less frequent in persons > 50 years Transmission in healthcare settings –Emergency, intensive care, other patient care Vaccine shortage early in season Sources: CDC, MMWR 2009 58 (RR10); Perez-Padilla et al, NEJM 2009 361(17); Wicker S et al, Dtsch Med Wochenschr 2009 134(48); Bertin M et al, Panel at Fifth Decennial Conference 2010; Safdar N, Poster at Fifth Decennial Conference 2010; CDC MMWR 2009 58.

6. 6 Influenza Vaccination of HCP Highly effective Simple, safe and cost effective Healthy People 2010 target: 60% Healthy People 2020 target: 90% Target during pandemic = 100% National rates remain low (~40%) Source: Pavia AT. Clin Infect Dis: 2010; 50:465-7.

7. 7 Why is influenza vaccination coverage low among HCP? Cost Access Perceived low risk of infection, illness Lack of efficacy Safety (influenza, adverse effects) Fear of needles General vaccination opposition

8. 8 Strategies to Increase Influenza Vaccination of HCP Free, accessible vaccine –All shifts, mobile carts, vaccination clinics, congregate areas Mandatory education –Risk of severe illness to HCP –Risk of transmission to patients and family Live attenuated influenza vaccine Source: CDC. MMWR: 2006; 55 (RR02): 1-16.

9. 9 Additional Strategies Track vaccination coverage –By unit or patient care area –Promote competition Offer incentives –Individual –Unit-based Administrative support –Provision of resources –Public vaccination of, support by leadership

10. 10 Mandatory Policies to Increase Influenza Vaccination among HCP Mandatory signed declination –Standard form, disincentive to decline Mandatory participation –Enforced with masks, reassignment Mandatory vaccination –Enforced with termination

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12. 12 Mandatory Signed Declination Few published studies with mixed results –In combination with other strategies has increased vaccination of HCP –Effective coverage shown without mandatory signed declination May not be effective as a stand-alone strategy Sources: Polgreen et al, Infect Control Hosp Epidemiol 2008, 29, 675-77; Ajenjo et al, Infect Control Hosp Epidemiol 2010 31, 233-40; Hirsch et al, Poster at Fifth Decennial Conference 2010; Rupp et al, Poster at Fifth Decennial Conference 2010.

13. 13 Who are HCP? “All paid and unpaid persons working in healthcare settings who have a potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated surfaces or contaminated air. HCP might include (but are not limited to) physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons (e.g. clerical, dietary, housekeeping, maintenance, and volunteers) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from HCP.” Source: Pearson ML, Bridges CB, Harper SA. MMW Recomm Rep: 2006; 55(RR02):1-16.

14. 14 HCP Defined All staff that work in a healthcare setting Paid or unpaid Potential for exposure to infectious materials or agents Regardless of direct patient contact

15. 15 HCP Defined in CA Mutually exclusive from employees paid by hospital May be paid or unpaid –Paid by another entity, i.e. contract or registry agency “Non-employee healthcare personnel”

16. 16 California Demographics Population37.3 million Acute care hospitals423 –Single license348 Licensed beds71,184 –ICU 6,247 –NICU 3,608 Discharges3.7 million Average length of stay4.3 days Source: US Census Bureau, 2010 Census; CDPH Licensing and Certification; Office of Statewide Planning and Development

17. 17 Influenza Vaccination Coverage of HCP in California and the United States Healthy People 2020 Healthy People 2010 Range Source: CDC/NCHS, National Health Interview Survey, 2005-2009

18. 18 2007-2008 Mandated annual reporting began Jan 1, 2008 –Middle of influenza season –Hospitals may not have had data collection systems in place Report on employees only –HCP not included as exclusive category Mean vaccination = 52% Response = 69%

19. 19 2008-2009 Advisory committee recommendation to include HCP –Confusion between employee and HCP –Many hospitals did not keep records on non-employee HCP Mean vaccination = 55% Response = 84% Unknown status = 17%

20. 20 2009-2010 Pandemic year –2009 influenza A (H1N1) Two vaccines –Report surveillance data on both for employees and HCP Confusion again with distinction between employees and HCP

21. 21 2009-2010 Mean vaccination –Seasonal = 63% –2009 influenza A (H1N1) = 55% Response = 82% Unknown status –Seasonal = 14% –2009 influenza A (H1N1) = 17% Mandatory policies –5 hospitals –Vaccination percentage >80%

22. 22 Impact of Mandatory Signed Declination? Modest increases from 2007-2010 in vaccination coverage of employees Required for paid employees, not for all HCP

23. 23 2010-2011 Piloted surveillance report form Captured paid employees and critical HCP groups first –Physicians, advanced practice nurses, physician assistants –Add HCP groups in subsequent years Used feedback questionnaire for input from pilot participants

24. 24 2010-2011 Pilot Results 21 randomly selected hospitals plus 3 correctional facilities 10 of 24 (42%) hospitals submitted feedback questionnaire 90% or more said form was easy to read with easy to follow instructions and definitions

25. 25 2010-2011 Pilot Results 80% or more reported definitions were clear 70-80% reported data on non- employee HCP were not easy to collect More than half of pilot hospitals could not report data for non-employee HCP

26. 2010-2011 Report Form

27. 27 Moving Forward Clear definitions of HCP are required Electronic vaccination surveillance is necessary Mandatory signed declination can be used as an adjunct strategy Alternative strategies to achieve 2020 target of 90%

28. 28 National Pilot Projects Pilot state to develop national quality measure for HCP influenza vaccination Pilot state to test national quality measure as an NHSN surveillance module

29. 29 http://www.cdph.ca.gov/programs/hai Patricia.mclendon@cdph.ca.gov