1. Increasing Influenza Vaccination Rates in Health Care Workers How Immunization Coalitions Can Help Wall Street Journal, Detroit Free Press, Reuters, Washington Post Margaret Bernard-Howe, RN Tulsa Area Immunization Coalitions

2. Decisions Tulsa Area Immunization Coalition Wanted an Influenza Vaccination Campaign impacting the most people Best Bang for the Buck? HCW influenza vaccination rates vs. general population “If my doctor/nurse doesn’t get a flu shot, WHY SHOULD I?” Goal-Target HCW and hope for the trickle down affect thus impacting much larger population

3. Concerted Effort Needed to Improve HCW Influenza Vaccination Rates Employers need to commit to institutionalize immunization programs in the workplace Immunization Coalitions can assist by providing materials and technical assistance needed to prepare, implement, and evaluate on-going programs

4. By the End of the Presentation Participants Will Be Able to: Identify problems with vaccine access and misconceptions leading to HCW’s non- vaccination Identify effective means to increase vaccination coverage Apply innovative strategies for developing, implementing, and evaluating a HCW Influenza Vaccination Program

5. Tulsa Area Immunization Coalition Established in 1997 T o immunize every Tulsan at the proper time for protection against vaccine preventable diseases To act as a catalyst for achieving local, state, and national immunization goals Motto “Immunize... Protect Lives!”

6. TAIC Partnerships– over 100

7. Two Partners in Particular Oklahoma State University- College of Osteopathic Medicine-Center for Health Sciences Tulsa City County Health Department

8. Influenza N N H

9. Highly contagious! spread by coughing, sneezing, direct physical contact, contact with fomites (e.g., doorknobs, phones) Contagious 1 to 4 days before onset of symptoms AND about 5 days after the first symptoms ~50% of infected people without symptoms, but still contagious! cdc.gov/flu/keyfacts Influenza Epidemiology

10. 6 th leading cause of death among adults ~ 36,000 deaths and 200,000 hospitalizations annually Transmission between HCWs and patients: serious problem in acute & long-term health care facilities Despite CDC recommendations, only 36-43% of HCWs vaccinated against influenza each year Low HCW immunization rates increase employee absenteeism and health care costs cdc.gov/flu/keyfacts Influenza Background

11. HCWs as the source of influenza transmission in health care settings: Employees continue to work while sick Unvaccinated workers who do not appear ill can still carry and spread the virus Influenza and HCWs* *HCWs= health care workers National Influenza Vaccine Summit Health Care

12. Vaccination Rates in Health Care Professionals National Foundation for Infectious Disease-Immunizing Healthcare Professionals-A Report on Best Practices

13. Benefits of Influenza Vaccination of HCWs Reduced risk of outbreaks in health care facilities Decreased employee illness and absenteeism Reduced health care costs caused by loss of productivity National Foundation for Infectious Disease-Immunizing Healthcare Professionals-A Report on Best Practices One study showed that a range of savings from $13- to more than $100 for each employee immunized

14. Reduction of Infection and Related Issues National Foundation for Infectious Disease-Immunizing Healthcare Professionals-A Report on Best Practices

15. Impact of Influenza on U.S. Hospitals, 2003-4* CDC Web-based survey of 221 U.S. hospitals, Dec 2003- Feb 2004 35% hospitals with staffing shortages during peak influenza epidemic 28% with bed shortages 43% with ICU bed shortages 9% with diversion of patients to other care facilities, with a mean of 6 days *unpublished data presented at ACIP, February 2004, Atlanta, GA

16. Health care organizations concerned about cost of vaccinating their employees, BUT costs of not doing so MUCH higher End result: net cost BENEFIT and SAFER environment for patients Level of vaccination coverage should be considered a measure of a patient safety quality program

17. Vaccine access Misconceptions leading to HCW' non- vaccination Identify problems

18. Common Misperceptions Vaccine itself can cause illness Real risks of influenza Role of the healthcare professional in transmitting the infection to patients Importance and safety of the vaccine The lack of, or perceived lack of, a conveniently available vaccine Lack of knowledge of CDC recommendations "Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices," MMWR, 2003.

19. Common Reasons for Not Getting Vaccinated Concern about safety or efficacy of the vaccine Sense of not being personally at risk (including having a “Healthy Immune System”) Lack of understanding of transmission Fear of needles Inconvenience of getting the vaccine "Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices," MMWR, 2003.

20. Flu Shot: Your Best Shot for Avoiding Influenza Influenza vaccination: THE most effective method available to prevent people from getting infected http :// www.osha.gov/Publications/OSHA_pandemic_health.pdf

21. http://www.immunize.org/catg.d/p2017.pdf

22. Identify Effective Means to Increase Vaccination Coverage Supported by various national accrediting and professional organizations

23. HICPAC & ACIP Recommendations HICPAC: The Healthcare Infection Control Practices Advisory Committee-CDC ACIP: Advisory Committee on Immunization Practices

24. Organizational Support for Increased Vaccination Coverage Joint Commission on Accreditation of Health-Care Organizations Approved infection control standard requiring accredited organizations to offer influenza vaccinations to staff Required after Jan. 1, 2007 Suggested by ACIP-Required vaccination or written declination Infectious Diseases Society of America Recommended mandatory vaccination for HCP Provision for declination of vaccination based on religious or medical reasons HCP= health care practitioner

25. New Joint Commission Standard Requirements Establish Annual Influenza Vaccination Program include at least staff & licensed independent practitioners Provide on-site access to vaccination Educate staff about flu vaccination, non- vaccination measures (appropriate precautions), diagnosis, transmission and potential impact of influenza Annually evaluate vaccination rates, reasons for non-participation Implement enhancements to program to increase participation

26. Innovative Strategies Reasons cited for receiving vaccine  Desire to protect themselves  Desire to protect patients  The convenience of receiving the vaccine  Peer influence  Prior positive experience when receiving vaccine TAIC Use What Works "Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices," MMWR, 2003.

27. TAIC’s HCW Influenza Program Based on Joint Commission’s recommendations Provides a complete one-stop source for all materials needed to prepare, implement, and evaluate programs and their progress TAIC = Tulsa Area Immunization Coalition

28. Developing the TAIC Program Management Commitment: Began with a letter to CEOs and top administrators of all major hospitals and large clinics asking for their support and commitment Emphasized HCW vaccination coverage level: considered a measure of a patient safety quality program

29. Initial letter asking for support (copies available…)

30. Public Awareness Campaign In Oct. 2007, City Life, a City of Tulsa Publication, included an insert on Flu Shots with customers’ water bills The insert, “Immunize! Flu shots can help prevent illness” reached over 140,000 customers The information sheet ended with: It’s up to you to stop the flu. Make sure your doctor has a flu immunization too.

31. City Life insert, included with > 140,000 customer’s water bills

32. City Life Insert Included a Specific HCW Recommendation

33. Implementing the Program Health Care Workers Influenza Vaccination Tool Kit

34. TAIC Members Hand Delivered Kits Tool Kits delivered to infection control and occupational health professionals responsible for influenza vaccination programs. The CD provides a one-stop location for links to different tools to facilitate influenza immunization of HCWs.

35. TAIC Health Care Workers Influenza Vaccination Tool Kit Tool Kits-used evidence-based approaches that maximize vaccination rates Based on recommendation from The Healthcare Infection Control Practices Advisory Committee (HICPAC) Advisory Committee on Immunization Practices (ACIP)

36. TAIC Tool Kit Includes: ACIP Recommendations for HCW ACIP Recommendations: Prevention and Control of Influenza MMWR, July 13, 2007 2007-8 Seasonal Influenza Information from the CDC

37. TAIC Tool Kit Includes Template Influenza Vaccination Policy Influenza Immunization Program Checklist Sample Employee Education Materials Standing Orders for Administration of Influenza Vaccine

38. TAIC Tool Kit Includes Medical Management of Adult Reactions Vaccine Adverse Event Reporting System (VAERS)

39. TAIC Tool Kit Includes Vaccine Administration Needle Sizes & Sites How to Administer IM & SQ Injections* Screening Forms Form for Declining Flu Shot by Employee Vaccine Information Statements on Influenza *IM=intramuscular; SQ= subcutaneous

40. TAIC Tool Kit Includes Guide to Contraindications and Precautions to Commonly Used Vaccines in Adults THE FLU GALLERY-Educational Material & Posters What is the Oklahoma State Immunization Information System (OSIIS) and how do I use it?

41. TAIC Tool Kit Includes Tracking Forms :  Totals-2007-8 Influenza Season  Totals-2006-7 Season-if known  Total # of staff for organization/clinic  Total # receiving flu vaccine  Total # for which flu vaccine contraindicated  Total # refusing vaccination (signed declination form)

42. Evaluating the Initial Results All vaccination Tally Sheets have not been received yet -23 Major Hospitals & Large Clinics For those reporting-(3) Sept 2007-present 52%-89% compliance (one Center- from 58%-70%, one Center-from 70%-89%) Giving additional vaccines/annual test- ( i.e., TB and Tdap) at the same time as the influenza vaccine increases #’s receiving vaccine.)

43. Lessons Learned Start Campaign Earlier- get more buy-in from CEO’s and Hospital & Clinic Administrators Target Quality Assurance Committees Educate JACHO accredited agencies- mandatory regulations Encourage Combined Programs- Tdap & Flu or TB annual testing & Flu vhs3.vahistorical.org/.../Influenza.1999.243.jpg

44. Overcome Obstacles Although this year’s influenza vaccine was NOT a good match for circulating virus… It is important to remember: even when viruses are not closely matched, vaccine still protects many people AND prevents flu- related complications. Antibodies made in response to the vaccine can provide some protection (called cross- protection) against different, but related strains of influenza viruses. Content Source: Coordinating Center for Infectious Diseases (CCID)

45. The Future Imperative that action be taken to improve health care worker vaccination rates. Voluntary programs have not succeeded in attaining acceptable immunization rates It may be necessary to develop new programs or legislation requiring influenza vaccination for ALL health care workers

46. An Ethical and Moral Duty Health care workers and health care systems have an ethical and moral duty to protect patients and workers on the job! Knowing the facts and not acting upon them is a dereliction of the responsibilities of the medical community to the safety of others!

47. Reassert Our National Leadership Role The medical community is now armed with clear, unambiguous data: Demonstrating health care workers are vectors in nosocomial influenza outbreaks Proving influenza vaccination is safe, effective, and cost efficient Showing HCW flu vaccination is successful in reducing patient morbidity and mortality

48. The Right Thing to Do Requiring influenza vaccination of health care workers is the right thing to do ! It benefits the patient, the employee, and the employer...

49. Thanks To all the TAIC Board Members and General Members for helping put together, distributing and data collection of the TAIC Health Care Workers Influenza Tool Kit To Oklahoma State University and the Tulsa City County Health Department for your time, efforts and assistance Immunization Coalitions can be a catalyst and leader in implementing immunization programs to increase vaccine immunization rates in not only Health Care Workers- but the general public.

50. References Influenza Vaccination of Health-Care Personnel Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) http://www.cdc.gov/mmwr/PDF/rr/rr5606.pdf 2007-08 Recommendations of the Advisory Committee On Immunization Practices (ACIP) Immunization Action Coalition and Hepatitis B Coalition CDC - Influenza (Flu) Health Care Workers & Influenza Overview http://www.nfid.org/pdf/publications/calltoaction.pdf CDC - Influenza (Flu) | Vaccination of Specific Populations (ACIP) AMA (Infectious Disease) National Influenza Vaccine Summit Health Care Worker Home Page http://www.ama-assn.org/ama1/pub/upload/mm/36/jcaho_standard.pdf Influenza Vaccination of Health-Care Personnel Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) http://www.apic.org/favicon.ico Immunizing Healthcare Workers Against Influenza Faces of Influenza, A Flu Prevention & Immunization Resource