SCarrots and Sticks:Influenza Vaccination of Healthcare Workers
Susan E Coffin, MD, MPHChildren’s Hospital of Philadelphia
July, 2011
Overview
Rationale behind HCW influenza vaccination
Implementing a mandatory flu vaccination program at CHOP
Impact of mandate• HCW attitudes• Nosocomial influenza
rates
HCW Flu Vaccination: background
• Vaccination of health care workers (HCW) decreases…▫ Healthcare-associated influenza infection▫ HCW absenteeism▫ Secondary infections among HCW’s 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
Nosocomial Influenza at CHOP (2000-2006)
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.
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
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
Direct Benefits of HCW Vaccination
Talbot, ICHE, 2005
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, 40 th National Immunization Conference Atlanta, March 2006
Cognitive Dissonance 101
Flu is bad for me and my patients.
Flu is bad for me and my patients.
I don’t get flu vaccine.
I don’t get flu vaccine.
Employer: “Get
Vaccinated!”
Employer: “Get
Vaccinated!”
I will get vaccinated.
I will get vaccinated.
Flu vaccine is unsafe.
Flu vaccine is unsafe.
Flu vaccine doesn’t work.
Flu vaccine doesn’t work.
You Can’t Make Me!!!
You Can’t Make Me!!!
?????
?????
I don’t get flu.I don’t get flu.
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
Are Declination Forms Enough?
PRO• HCW vaccination no
longer a “passive decision”
• Provides final opportunity to frame issue
• Creates focus on individual accountability
CON• Signals acceptance of non-
vaccination
• Polarizing effect reported by some
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
2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 2009-2010
57% 69% 73% 90% 92% 99.6%Targeted group(s) Direct care providers* in
high risk settings#
All direct care providers*
All^ who work in building where patient care is delivered
Education and Communication
Mandatory education module included in fall core curriculumLinked to pandemic flu preparedness
Linked to patient safetyRemedial education$
Town hall meetings
Logistics Expanded Occupational Health clinic hours
Unit- and practice-based flu captainsFlu vaccine clinics held at meetings
Roving vaccination cartsDeclination Form None None
VoluntaryMandatory
Administrative Senior administration stresses importance of flu vaccination to clinical leaders
Biweekly compliance reports@
Weekly compliance reports@
Use of LAIV ^ Offered to providers who did not work in high risk setting#
Offered to all providers except those who worked on oncology unit
Why CHOP HCW decline flu vaccine
2005-2006 2006-2007
Allergy/Reaction 39 26
Rec’d 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
Vaccination of physicians
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
perce
nt va
ccina
ted
16% MD groups >80% (5/31)
53% MD groups >80% (19/36)
22% MD groups fully vaccinated (8/36)
81% of MDs vaccinated (623/777)
0
10
20
30
40
50
60
70
80
90
100
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2007-2008 2008-2009
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.
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
Program Timeline, 2009-2010PLAN: • 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
What happened: 2009-2010•>9000 HCW vaccinated
•50 persons established medical exemptions
•2 persons established religious exemptions
•145 received temporary suspension
•9 persons terminated
Labor Relations 101
•2 meetings to negotiate▫Impasse declared
Quotes from 10/26/09 negotiation:•“You’re not making sure everyone who
comes into CHOP is vaccinated.”
•“Why can’t 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.”
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
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 CHOP’s patient population.”
•“It is this Arbitrator’s finding that the policy implemented by the Hospital was reasonable in the context of the Hospital’s young, vulnerable patient community.”
Year 2 Experience: 2010-2011•>9500 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.
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 (electronic>>paper distribution)
8,093 HCW’s
25% clinical
(n=1450)
50% non-
clinical(n=1100)
Study Question:What predicts agreement with the mandate?
•Primary outcome: attitude towards influenza vaccine mandate▫“Do you agree with CHOP’s 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”
Results: Survey
• Response rate (58%):▫1,388 respondents (total distributed = 2,443)
657 (47%) clinical 731 (74%) nonclinical
• Respondent characteristics:▫77% female▫65% < 45 years of age▫68% have worked at CHOP <10 years▫90% staff previously vaccinated
• 91% felt they had received info they needed from CHOP to make decision about flu vaccination
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
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
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
• >95% of both groups agree with policies for requiring vaccination or screening for TB, HepB, measles, rubella and varicella
Predictors of Agreement with MandateDemographic 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
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 benefits29.0 (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)
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 benefits29.0 (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)
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
Do Mandates Improve Patient Outcomes?
• 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
Summary
Questions?
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
