Presentation on theme: "Influenza Vaccination: Providing Standard of Care Presentation to: Georgia Hospital Association Presented by: Matthew B. Crist, MD, MPH Date: September."— Presentation transcript:
Influenza Vaccination: Providing Standard of Care Presentation to: Georgia Hospital Association Presented by: Matthew B. Crist, MD, MPH Date: September 27, 2012
Outline Who should be vaccinated and vaccines offered Contraindications and side effects Strain selection and manufacturing of vaccine Healthcare Worker Vaccination – Working Sick – Mortality Benefit – Improving vaccination rates – Mandates
Who gets the flu? From % of the U.S. population develops influenza each year. This leads to more than 200,000 hospitalizations from related complications. Persons at higher risk for complicated flu are: – People with asthma – People with diabetes – People with heart disease or history of stroke – People >65 years of age – Pregnant women – People with HIV infection – People with cancer – Children <5, especially those <2 years of age
Who should get the shot? Annual vaccination is recommended for all persons aged 6 months and older.
Contraindications Under 6 months of age History of anaphylactic reaction to vaccine or eggs Moderate-to-severe illness with a fever (wait until they recover) Guillain-Barre syndrome within six weeks of a previous influenza shot in a person not at high risk for complications from influenza – If the risk from influenza is high, they should be vaccinated because the established benefits of the vaccine justify vaccination
Contraindications to LAIV History of asthma or other reactive airway diseases Chronic medical conditions that predispose to severe influenza infections Pregnancy History of Guillain-Barre syndrome Acute serious illness with fever LAIV should not be given concurrently with other live-virus vaccines
Adverse Reactions TIV – Soreness, redness, or swelling at the injection site – Fainting – Low grade fever – Muscle aches – Nausea LAIV – Runny nose – Headache – Sore throat – Cough Can occur shortly after vaccine is given and usually last 1-2 days
Adverse Reactions: Severe Anaphylactic Reaction- Occur in less than 1 in 10,000 Guillain-Barre Syndrome- Occur in approximately 1 in a million Febrile Seizures- Increase associated with vaccine in Australian vaccine which is not used in the US Safety is Monitored through – Vaccine Safety Datalink Project (VSD) – Vaccine Adverse Event Report System (VAERS)
What’s on the horizon? Quadrivalent live attenuated influenza vaccine, FluMist Quadrivalent® (MedImmune) was approved February 2012 – Live, attenuated influenza vaccine – Administered as a nasal spray – Approved for use in people ages 2 through 49 years – The first to contain four strains of the influenza virus -- two influenza A and two influenza B lineage strains. – Anticipated to be available for US season Vaccines from cell-based media Universal Vaccine?-target the stem of the hemagglutinin surface protein
Vaccine Strain Selection Process 130 national influenza centers in 101 countries conduct year- round surveillance for influenza and send influenza viruses to the 5 WHO Influenza collaborating centers : – Atlanta, GA (CDC) – London, UK(National Institute for Medical Research) – Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory) – Tokyo, Japan (National Institute for Infectious Diseases) – Beijing, China (National Institute for Viral Disease Control and Prevention) – Experts from the FDA, the WHO, the CDC, and other public health experts identify virus strains likely to cause the most illness during the upcoming flu season.
Vaccine Strains for The strains selected for inclusion in the flu vaccines are: – A/California/7/2009 (H1N1)-like virus – A/Victoria/361/2011 (H3N2)-like virus – B/Wisconsin/1/2010-like virus.
INFLUENZA VACCINATION IN HEALTHCARE WORKERS
Prevention of Healthcare-Associated Influenza Early identification/isolation of suspect cases Source control/mask patient Restrict ill visitors/healthcare personnel Hand hygiene Vaccination of patients PPE Antiviral prophylaxis Vaccination of HCP
Talbot TR et al ICHE 2005;26:882+ Frequent contact with high-risk patients Serve as a vehicle for spread of flu HCP absenteeism can stress health system Influenza vaccination of HCP may reduce patient mortality Model for their patients Why is Healthcare Personnel Influenza Vaccination Important?
Talbot TR ICHE 2005;26:882 Stott DJ Occ Med 2002;52:249 Foy HM Am J Epi 1987;126:506 Weingarten S AJIC 1989;17:202 Lester RT ICHE 2003;24:839 Healthcare-Associated Influenza Outbreaks reported in most care areas Influenza infection causes minimal or no symptoms in up to 25% Such workers still shed (and spread) virus 76.6% HCP work while ill with ILI Worked mean 2.5 days while ill with ILI
Risk of HA-ILI in Acute Care Setting Prospective surveillance of pts and HCWs App 20-25% ILI = influenza Vanhems P et al Arch Intern Med 2011;171:151+ Unit Influenza Vaccination Coverage # HCWs Infected with Influenza Transmission Bet HCWs Unit A 75%10 Unit B5.3%53
Healthcare personnel influenza vaccination coverage, US mid-November 2011 Population Unweighted sample size * Weighted n Coverage % (95% CI) Overall 2,44213,337, (60.7, 66.1) Occupation: Physician/ Dentist , (73.7, 81.5) Nurse practitioner/ physician assistant , (69.5, 84.1) Nurse 3982,814, (71.1, 80.4) Other † 1,4499,743, (55.3, 62.0) † "Other" includes allied health professionals, technicians/assistants and aides, and administrative and non-clinical support staff.
Healthcare worker influenza vaccination coverage by age, US mid-November 2011
Healthcare personnel influenza vaccination by work setting, US mid-November 2011
Reason for healthcare worker reporting they will not be vaccinated during the flu season, US mid- November 2011
Heimberger T ICHE 1995;16:412 Lester RT ICHE 2003;24:839 Martinello RA ICHE 2003;24:845 Nichol KL ICHE 1997;18:189 Steiner M ICHE 2002;23:625 Weingarten S AJIC 1989;17:202 Reason% (Range) Inconvenient/Too busy/Forgot15-83 Concerned for vaccine adverse events27-66 Perception of low risk for influenza15-23 Cost1-5 Fear of needles/Vaccine-averse8-18 Vaccine not effective8-24 Egg allergy1-7 Reported Reasons for Low HCP Vaccination Rates
HCP Vaccination & the Impact Upon Patient Mortality Patient Mortality (%) 6 LTCF/ arm N = 1059 pts 10 LTCF/ arm N = 1437 pts 22 LTCF/ arm N = 2604 pts 20 LTCF/ arm N = 3483 pts ns
Lemaitre M et al JAGS 2009 Lower patient mortality significantly correlated with HCP vaccination coverage
Salgado CD et al ICHE 2004;25:923+ Lower nosocomial influenza frequency significantly correlated with higher HCP vaccination coverage
Talbot TR ICHE 2005;26:882 Methods to Improve HCP Vaccination Rates Make it a priority: – Strong and visible administrative leadership – Visible vaccination of key leaders – Vaccination champions – Provision of adequate staff and resources – Train-the-trainer programs that empower unit staff Make it available: – Off-hours clinics – Use of mobile vaccination carts – Vaccination at staff/departmental meetings – Provision of vaccine free of charge
Talbot TR ICHE 2005;26:882 Methods to Improve HCP Vaccination Rates Tackle the myths: – Targeted education – Assess comprehension of the message Monitor and feedback progress: – Tracking of individual & unit-based HCP vaccination compliance – Surveillance for healthcare-associated influenza Make it mandatory/hard to refuse – Signed declination statements – Condition of employment
Talbot TR Clin Infect Dis 2009;49:773+
DECLINATION OF VACCINE - You MUST complete if refusing vaccine I am eligible to receive the influenza vaccine BUT do not want to take it. I understand that by refusing the vaccine I may be putting my FAMILY, FRIENDS and PATIENTS at risk of getting influenza. I am aware that hospitalized patients are at increased risk of getting serious complications following influenza infection. Please CHECK YOUR REASON(S) for not receiving the influenza vaccine. Afraid of needles Afraid of side effects Fear of getting influenza from the vaccine Don’t believe in vaccines Don’t think vaccines work I never get the flu Other: _____________________________________________________________________________
Mandates and Healthcare Workers
Conditions for Employment in Healthcare Conditions for employment in place at many facilities – MMR or evidence of immunity – Hepatitis B vaccine series, evidence of immunity, or signed declination – Annual tuberculin skin testing – Varicella vaccine if no evidence of immunity
Sources: University HealthSystem Consortium, Emerging Infections Network Virginia Mason Medical Center 2005
Virginia Mason Medical Center Mandatory Influenza Vaccination Program Rakita RM et al Infect Control Hosp Epidemiol 2010;31:881+
Sources: University HealthSystem Consortium, Emerging Infections Network Virginia Mason Medical Center 2007
Sources: University HealthSystem Consortium, Emerging Infections Network BJC Healthcare (11 hospitals) Virginia Mason Medical Center 2008
Babcock HM et al CID 2010;50:459+
Talbot TR Clin Infect Dis 2009
Sources: University HealthSystem Consortium, Emerging Infections Network BJC Healthcare (11 hospitals) CHOP/ Hospital of UPenn MedStar Health (9 hospitals) U of Iowa Virginia Mason Medical Center NC Baptist Hospital (Wake Forest) Emory Health Systems 2009
Sources: University HealthSystem Consortium, Emerging Infections Network BJC Healthcare (11 hospitals) CHOP/ Hospital of UPenn MedStar Health (9 hospitals) U of Iowa Virginia Mason Medical Center 163 Hospitals, 20 states NC Baptist Hospital (Wake Forest) Emory Health Systems 2009/10
Sources: University HealthSystem Consortium, Emerging Infections Network BJC Healthcare (11 hospitals) CHOP/ Hospital of UPenn MedStar Health (9 hospitals) U of Iowa Virginia Mason Medical Center 163 Hospitals, 20 states NC Baptist Hospital (Wake Forest) Emory Health Systems Johns Hopkins System U. Wash. Medicine B-I Deaconess/ Children’s Hospital Boston
Commonalities Among Those Institutions/Healthcare Systems That Have Mandated Influenza Vaccination of HCP Dissatisfaction w/ rates already above national average Strong leadership advocacy – Willing to take brunt of opposition Patient and HCP safety emphasized Initial implementation = intense – Resources – Challenges (HCP, unions) Engrains into culture “No big deal” (eventually) Rates ≥ 95%
Professional Societies and Organizations Endorsing Mandatory Influenza Vaccination of Healthcare Personnel Updated 2/13/2012
Communication of Policy Daugherty et al. ICHE 2011
Communication In summary, our findings suggest a need for more investigation of factors influencing HCW beliefs about vaccine effectiveness in order to tailor policies and programs to address not just adherence but the drivers behind it. Although we agree that mandatory vaccination will likely significantly improve adherence, the perception of unfairness and excessive pressure on the part of the institution is not a trivial concern. Policies that foster trust, rather than mistrust and resentment, are likely to be far more effective in the long run. Daugherty et al. ICHE 2011
Acknowledgements Tom Talbot, MD, MPH: Vanderbilt School of Medicine Christine Hahn, MD: Idaho Dept. of Health and Welfare Delmar Little, MPH: Georgia Dept. of Public Health Jeanne Negley, MBA: Georgia Dept. of Public Health
Surveillance (Extra Slides)
Influenza A (H3N2) Variant Virus Outbreak Appears to spread more easily from pigs to people than other variant viruses. Main risk factor is exposure to pigs, mostly in fair settings. Most cases have occurred in children. Only limited person-to-person spread with this virus has occurred. Symptoms are similar to seasonal flu. People at high risk of serious complications include: – children < 5 – people with chronic conditions like asthma, diabetes, heart disease, weakened immune systems, pregnant women and people >65 years – These people are urged to avoid pigs and pig arenas at fairs this season.
Influenza A(H3N2) Variant Virus (aka“H3N2v”) Influenza A (H3N2) viruses with genes from avian, swine and human viruses that normally circulate in swine can sometimes infect humans. When these viruses are found in swine, they are called swine influenza A (H3N2) viruses. When human infections with these viruses occur, these viruses are called “variant” viruses (which can also be denoted with the letter “v”). In 2011, a new influenza A (H3N2v) virus was detected that had acquired the M gene from the influenza A(H1N1)pdm09 (2009 H1N1) virus. Continued human infections with this H3N2v virus have been detected in the US.
Diagram of swine-origin trH3N2
Summary of Ongoing H3N2v infections Influenza A (H3N2) viruses with genes from avian, swine and human viruses that normally circulate in swine can sometimes infect humans. Current outbreak of cases started in July total variant cases in 2011 As of Sept. 14 th, there were now 306 H3N2v total cases, 16 hospitalizations, and 1 death in 11 states. Cases have presented with mild illness 90% of cases are aged 10 and younger Main risk factor for infection is exposure to pigs, mostly in fair settings, However, CDC has previously reported the identification of likely cases of human-to-human spread of this virus during the current outbreaks.
Summary of Ongoing H3N2v infections No cases have been observed in Georgia Enhanced surveillance by ILINet provider and District Epidemiologist Public Health messaging has been jointly developed and disseminated by Public Health and the Department of Agriculture Public health has also coordinated with the 4-H club, Jr. swine exhibitors, and Fair coordinators, to distribute education and prevention messages. GET YOUR Seasonal FLU SHOT!!