Promoting Flu vaccination for Health Care Workers 7th June 2011 Promoting Flu vaccination for Health Care Workers Insert name of presentation on Master Slide Dr Brendan W Mason Regional Epidemiologist

Why bother? Trivalent seasonal influenza vaccine should be offered to: Health care staff directly involved in the care of patients. Others involved directly in delivering health care such that they and vulnerable patients are at increased risk of exposure to seasonal influenza. JANUARY 2011 UPDATE http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_123590.pd UK Policy

Copyright Leah Millinship Why bother? “Getting employees vaccinated against the flu should be a corporate health priority as low uptake levels may put the people being cared for at risk.” “NHS organisations should proactively encourage those directly involved in patient care to be vaccinated.” LETTER FROM HEALTH MINISTER TO CHAIRS NHS HEALTH BOARDS 1st JULY 2010 http://wales.gov.uk/docs/dhss/publications/100713ml02510en.pdf Copyright Leah Millinship Welsh Policy

Why bother? Prevent transmission of influenza from HCWs to patients Patients at increased risk of acquiring influenza Patients at increased risk of death or serious illness from influenza Avoid disruption to services that provide patient care Protect HCWs from influenza Protect families HCWs from influenza Intended outcome of policy

Why bother? How big is the problem? How effective is the intervention? Health impact

Protecting patients: systematic review effectiveness Influenza vaccination for HCWs who work with the elderly: 4 cluster randomised controlled trials (n = 8468) over 60s in long term care facilities Statistically significant reductions: Influenza-like illness (ILI); GP consultations for ILI; all-cause mortality. Non significant reductions: Laboratory confirmed influenza; pneumonia; deaths from pneumonia. Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD005187. DOI: 10.1002/14651858.CD005187.pub3. Evidence base

Protecting patients: systematic review effectiveness Outcome Number studies Number patients Relative Risk 95% CI Influenza-like illness 3 7031 0.71 0.55-0.90 Confirmed Influenza 2 752 0.86 0.44-1.68 GP consultations ILI 1 2572 0.48 0.38-0.61 Pneumonia 1059 0.70 0.41-1.20 Death from pneumonia 4459 0.82 0.45-1.49 Death from all causes 4 8468 0.66 0.55-0.79 Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD005187. DOI: 10.1002/14651858.CD005187.pub3. Evidence base

Protecting patients: systematic review effectiveness All cause mortality in patients in units where HCWs offered flu vaccine estimated to be 66% of level in units where HCWs not immunised = One third reduction in deaths in patients in units where HCWs offered immunisation 95 % confidence interval estimate reduction in mortality 21% to 45% . Outcome Number studies Number patients Effect Size 95% CI Influenza-like illness 3 7031 0.71 0.55-0.90 Confirmed Influenza 2 752 0.86 0.44-1.68 GP consultations ILI 1 2572 0.48 0.38-0.61 Pneumonia 1059 0.70 0.41-1.20 Death from pneumonia 4459 0.82 0.45-1.49 Death from all causes 4 8468 0.66 0.55-0.79 Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD005187. DOI: 10.1002/14651858.CD005187.pub3

Protecting patients: systematic review effectiveness Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD005187. DOI: 10.1002/14651858.CD005187.pub3

Protecting patients: systematic review effectiveness Over a 4-5 month period of high influenza activity: 13% (555/4258) patients died in units where HCW not immunised 9% (381/4210) patients died in units where HCW offered immunised Absolute reduction in all cause mortality 4% Highly statistically significant p=0.00001 Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD005187. DOI: 10.1002/14651858.CD005187.pub3

Protecting patients: economic evaluation Most likely scenario Vaccination HCW was cost saving Saving of £12/vaccinee Most pessimistic scenario Cost £405/life-year gained Burls A et al. Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006;24:4212–21. Evidence base

Protecting patients: economic evaluation Most likely scenario Typical Welsh Health Board saving £175,000/year Most pessimistic scenario Cost £405/life-year gained Cf. NICE cost effectiveness threshold £30 000 per quality adjusted life year (QALY) gained Effective implementation should be a priority. Burls A et al. Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006;24:4212–21. Evidence base

Protecting HCWs: systematic review effectiveness Influenza vaccines in healthy individuals aged 16 to 65 years: 40 randomised controlled trials (n = 70,000) Statistically significant reductions: Influenza-like illness (ILI); Laboratory confirmed influenza; working days lost; antibiotics prescribed. Non significant reductions: GP consultations; pneumonia; hospital admission. Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD001269. DOI: 10.1002/14651858.CD001269.pub4. Evidence base

Protecting HCWs: systematic review effectiveness Outcome When circulating virus matches vaccine Number studies Number patients Relative Risk 95% CI Influenza-like illness 10 6984 0.70 0.59-0.83 Confirmed Influenza 8 11285 0.27 0.16-0.46 GP visits 1 1178 0.58 0.37-0.91 Hospital admission 2 2590 0.37 0.12-1.12 Pneumonia 1402 0.59 0.04-9.43 Working days lost 4 4263 Mean -0.21 -0.36 to -0.05 Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD001269. DOI: 10.1002/14651858.CD001269.pub4. Evidence base

Protecting HCWs: systematic review effectiveness 73% reduction influenza in immunised HCWs Immunised HCWs will on average take off 0.2 days less than unimmunised HCWs Every 5 HCWs immunised will result in an extra day staff availability to provide clinical care Outcome When circulating virus matches vaccine Number studies Number patients Relative Risk 95% CI Influenza-like illness 10 6984 0.70 0.59-0.83 Confirmed Influenza 8 11285 0.27 0.16-0.46 GP visits 1 1178 0.58 0.37-0.91 Hospital admission 2 2590 0.37 0.12-1.12 Pneumonia 1402 0.59 0.04-9.43 Working days lost 4 4263 Mean -0.21 -0.36 to -0.05 Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD001269. DOI:10.1002/14651858.CD001269.pub4.

Protecting HCWs: systematic review effectiveness In general population healthy adults aged 16-65 years when vaccine and circulating strain match: 4% of unvaccinated develop influenza 1% of vaccinated develop influenza Absolute risk difference 3% 95% CI difference 2% to 5% Risks infection HCW vs population unknown. Close contact with cases may mean risk acquiring infectinis higher and thus absolute benefit greater. Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD001269. DOI:10.1002/14651858.CD001269.pub4.

Conclusion In an ideal world more high quality research Larger studies in more specific staff and/or patients groups To demonstrate effects on less common outcomes and improve generaliseability However, available evidence is consistent Effective and cost effective for both staff and patients Evidence base

How are we doing? 2010-11 influenza immunisation uptake in Occupational Health

How are we doing? Improving

How are we doing? Improving, but some way to go.

How are we doing? Uptake in different staff groups

Increase uptake in HCWs What have you done? What worked? Share experience

Why are HCWs not immunised? 21 studies in 9 countries. Weighted score. Hollmeyer FH et al. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine 2009;27:3935-44.

Why are HCWs immunised? 21 studies in 9 countries. Weighted score. Hollmeyer FH et al. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine 2009;27:3935-44.

Intervention to increase uptake Components Definition Examples Education or promotion Efforts to raise awareness and/or increase knowledge about influenza and influenza vaccine Educational sessions Educational materials Events promoting vaccination Incentives Improved access to vaccine Strategies to allow easier access to vaccination for HCWs Mobile vaccine carts Peer to peer vaccination Additional clinics Extended opening clinics Legislation or regulation Interventions involving changes in vaccination policy for HCWs Employer policy Declination forms Mandatory immunisation Measurement and feedback Tracking of uptake rates in HCWs and dissemination of results Regular reporting uptake to managers and/or HCWs Role models Activities that involve leaders and/or senior staff to encourage vaccination Advocates and champions Public support Visible immunisation Types of interventions Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010;182(12):542-8.

Intervention to increase uptake Not exposed Exposed Change uptake Education or Promotion Dey et al. Educational session & materials 6% 10% +4% Kimura et al. Educational Video 30% 36% +7% Lemaitre et al. 32% 69% +37% Improved access Free vaccine day 49% +20% Education + improved access Educational Video & Free vaccine day 58% +29% Education + access +legislation + role model Hayward et al. Educational letter & out hours clinics & policy & training lead nurse advocates 5% 35% +30% Number are correct. Rounding errors! (36.29719854% -29.66381015% = 6.633388387% becomes 36%-30% = 7%) Red statistically significant. All cluster RCTs NOTE: Rounding errors! Red statistically significant Randomised controlled trials: community Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8.

Intervention to increase uptake Not exposed Exposed Change uptake Education or Promotion Doratotaj et al. Letter from infectious disease department 38% 39% +1% Raffle ticket for $3000 vacation 42% +4% Letter from infectious disease department & Letter from infectious disease department 45% +7% Ohrt et al. Letter from chief of infectious disease 8% 22% +14% Personalised phone call 11% 20% +9% Number are correct. Rounding errors! Red statistically significant. All small individual RCTs c. 100-200 per arm. Underpowered to detect intervention effect. Randomised controlled trials: hospital Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8.

Intervention to increase uptake Before After Change uptake Education + improved access Tannenbaum et al. Information sessions by doctors & informational memos + posters & extra clinics 10% 24% +14% Thomas et al. Vaccination fair 8% 46% +38% Number are correct. Rounding errors! Red statistically significant. Before and after trials: community Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8. Talbot R. Do declination statements increase health care workers influenza vaccination rates? CID 2009;49:773-9.

Intervention to increase uptake Before After Change uptake Education or Promotion Zimmerman et al. Incentive (lottery gift card) 34% 38% +4% Improved access Mobile vaccine cart 39% Sartor et al. 7% 32% +25% Cooper et al. 8% 49% +41% Education or Promotion+ improved access Harbarth et al. Educational meeting & mobile cart 23% 37% +15% Improved access + measurement feedback Polgreen et al. Vaccines at meetings & feedback uptake to directors 58% 61% +3% Legislation Declination statement 54% 65% +11% Bertin et al. 55% +17% Ribner et al. 43% +22% Hagar Mandatory vaccination 30% 98% +68% Babcock et al. 71% 99% +28% Intervention to increase uptake Number are correct. Rounding errors! Red statistically significant. Before and after trials: hospital Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8. Talbot R. Do declination statements increase health care workers influenza vaccination rates? CID 2009;49:773-9.

Mandatory vaccination Introduced in US and Australia ? culturally more acceptable US require immunisation for school attendances In general not in keeping with UK approach Immunity to hep B required for EPPs A step too far for the UK?

Declination statement Influenza Vaccine Declination Form Health Board / NHS Trust Name: __________________________ You have given me the opportunity to be vaccinated with the influenza vaccine at no cost to myself. I have received, read and understand information about the risks and benefits of the 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 MYSELF and my FAMILY, FRIEND, and PATIENTS at risk of getting influenza. I am aware that hospitalised patients are at increased risk of developing serious complications and death following influenza infection. However, I decline the influenza vaccine at this time. ____________________________________ Employee’s Name (Print) _____________________________________ Employee’s Signature ______________________________________ Date Should be considered?

Conclusion Influenza vaccination protects HCWs and their patients. Influenza vaccination is highly cost effective, and potentially cost saving for the NHS. Multifaceted interventions are required to improve uptake in the NHS in Wales. What are you going to do?

Copyright Leah Millinship What are you going to do? Copyright Leah Millinship Organised efforts will succeed

References Intervention studies to increase uptake Polgreen PM, Septimus EJ, Parry MF, et al. Relationship of influenza vaccination declination statements and influenza vaccination rates for healthcare workers in 22 US hospitals. Infect Control Hosp Epidemiol 2008; 29:675–7. Bertin M, Scarpelli M, Proctor AW, et al. Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program. Am J Infect Control 2007; 35:33–7. Buchta WG, Verdoon CA, Schultz GL. Effectiveness of declination statements in influenza vaccination programs for healthcare workers [abstract 348217]. In: Program and abstracts of the International Commission on Occupational Health (ICOH) Conference on Health Care Worker Health/2007 State-of-the-Art Conference (Vancouver, British Columbia, Canada). International Commission on Occupational Health, 2007. Ribner BS, Hall C, Steinberg JP, et al. Use of a mandatory declination form in a program for influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol 2008; 29:302–8. Polgreen PM, Polgreen LA, Evans T, Helms C. A statewide system for improving influenza vaccination rates in hospital employees. Infect Control Hosp Epidemiol 2009; 30:474–8. Sartor C, Tissot-Dupont H, Zandotti C, Martin F, Roques P, Drancourt M. Use of a mobile cart influenza program for vaccination of hospital employees. Infect Control Hosp Epidemiol 2004; 25:918–22. Cooper E, O’Reilly M. A novel staff vaccination strategy. Infect Control Hosp Epidemiol 2002; 23:232–3. Harbarth S, Siegrist CA, Schira JC, Wunderli W, Pittet D. Influenza immunization: improving compliance of healthcare workers. Infect Control Hosp Epidemiol 1998; 19:337–42. Thomas DR, Winsted B, Koontz C. Improving neglected influenza vaccination among healthcare workers in long-term care. J Am Geriatr Soc 1993; 41:928–30. Dey P, Halder S, Collins S, Benons L, Woodman C. Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial. J Public Health Med 2001; 23:346–8. Doratotaj S, Macknin ML, Worley S. A novel approach to improve influenza vaccination rates among health care professionals: a prospective randomized controlled trial. Am J Infect Control 2008; 36:301–3. Babcock HM et al. Mandatory influenza vaccination of health care workers:translating policy to practice. Clin Infect Dis 2010; 50: 459–64. Hagar BA. 2008 42nd NIC National Immunization Conference: Mandatory influenza vaccination: the Virginia Mason Story. Available at: http://cdc.confex.com/recording/cdc/nic2008/ppt/free/4db77adf5df9fff0d3caf5cafe28f496/paper15824_5.ppt Zimmerman RK, Nowalk MP, Lin CJ, et al. Factorial design for improving influenza vaccination among employees of a large health system. Infect Control Hosp Epidemiol 2009;30:691-7. Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333:1241 Intervention studies to increase uptake