1. Declination Forms – Do They Work? Southern California Marlene M. Lugg, Dr. P.H. Immunization Coordinator / Project Manager

2. Kaiser Permanente - Non-profit group model HMO Comprehensive Health Care Southern California For 3.3 million members and 40,000 births/year At 11 hospital/medical centers and 100+ outpatient clinics By over 3,000 providers

3. History: Annual influenza immunization rates for employees prior to 1997 were 30-35% in spite of promotion and incentives: On-site flu clinics for 3-4 weeks “Flu Cart” traveling around clinics “Flu Cart” traveling though hospital on all shifts Monetary and other incentives

4. 1998 Strategy Memo from Medical Director included with paychecks on October 1 Persons who were vaccinated were eligible to win incentives in weekly drawings (Gift Certificates to local stores and Grand Prize - Cruise to Hawaii for two)

5. 1998 Strategy Details On October 1, Medical director’s memo/form included with all paycheck, asking all employees to be vaccinated in order to protect themselves, their families, and patients Form signed when vaccinated, or reason for declining vaccine noted. Forms turned in to employee’s department manager. Department managers follow-up and try to collect forms from all employees. No sanctions if forms not used

6. 1998 Progress –By November 20 at One Medical Center 60.&% of all employees had turned in forms 83.3% vaccinated 16.7% refused 50% of all employees vaccinated

7. 1998 reasons for declining flu immunization Afraid I will get sick from the shot Had it before and it didn’t work. I got sick anyway I’m afraid of needles I’m allergic to eggs Pregnant or nursing MD said not to Good immune system, don’t need it I’m healthy, eat well. Just don’t want it.

8. Results at End of 1998 Flu Season 39,174 Employees 19,745 (49.6 %) turned in forms 16,776 Vaccinated (85 %) 2,969 Declined 19,429 (50.4 %) did not turn in forms Overall employee immunization rate = 43.6%

9. The Years 1998-2007 Between 1998 and 2007, employee influenza vaccination rates for Southern California Kaiser Permanente ranged between 40 and 50%

10. 2007 Environment change SB739 (Infection Control) became law, amending the California State Health and Safety Code: Free flu vaccine to be offered to all acute care hospital employees “Each acute care hospital shall require its employees to be vaccinated, or if the employee selects not to be vaccinated, to declare in writing that he or she has declined the vaccination.”

11. Kaiser Permanente Response to SB 739 Southern and Northern California Kaiser Permanente mandated flu vaccination for ALL their employees.

12. 2007 Strategy Declination form to be turned in if not taking vaccination Employee Health Department tacked vaccinations (using Kaiser Immunization Register - KITS and declination forms) No monetary incentives, no prizes Employment incentive – employees not being vaccinated or turning in declination form by end of January would be suspended from work until they had done so.

13. 2007 Strategy, continued Flu Mist offered for the first time Declination reasons shown on form: I don’t believe the vaccine will work I am concerned about side effects I am afraid of injections Other.. “I understand that I am required by Kaiser Permanente policy to complete and sign this form as a condition of my employment”

14. 2007 Results December 31, 2007 Examples of flu shot acceptance by different employee groups at two Medical Center complexes

15. Medical Center 1 lower income demographic area

16. Medical Center 2 higher income demographic area

17. January 15 Intervention E-mails were sent to all department managers listing employees who did not have vaccination and did not turn in declination form. Employees were notified by their department managers that they would be suspended from work if they did not comply by the end of January.

18. What did notified employees do? Said they had the shot, and brought in proof, which was entered into the KITS and Employee Health computer systems. Said they had the shot but did not have proof – were told to sign declination form. Said they still didn’t want the shot - were told to sign the declination form.

19. Southern California Kaiser Permanente Employee Flu Vaccination and Declination Rates January 31, 2008

20. Comparison and Conclusion YearVaccinated Refused with form Refused no form Prior to 1998 no forms30-40 %n/a60-70 % 1998 voluntary form43.6 %6.4 %50.4 % 1999- 2006 no forms40-50%n/a50-60 % 2007 mandated form63.9 %33.4 %2.5 %

21. Acknowledgement Thanks to all the dedicated Immunization Coordinators, physicians, and staff who work tirelessly to implement vaccine policies in order to protect our members. Quality Patient Care! KEEP OUR MEMBERS HEALTHY!