Improving Influenza Vaccine Coverage Levels among Nursing Home Health Care Workers Akiko C. Kimura, MD Jeffrey Higa, MPH Christine Nguyen, MPH California Department of Health Services Infectious Diseases Branch

Overview Background/scope of the problem Knowledge, attitudes, and behaviors study of nursing home (NH) health care workers (HCWs) NH HCW intervention study

Background Annual influenza epidemics NH residents vulnerable >100,000 hospitalizations, >30,000 deaths >90% of deaths occur in those ≥65 yrs old NH residents vulnerable Due to: underlying medical conditions living in close proximity contact with a range of caregivers 60% infected during outbreaks, 25% require hospitalization

California Elderly & NHs CA elderly (≥65 years) 2000: 3.6 million (10% CA pop.) 2050: 9.9 million (18% CA pop.) >1200 NHs in CA (2003) 2000: 100,000 residents 2050: 175,000 residents

NH HCWs Source of NH influenza outbreaks even with high resident vaccination rates Higher NH HCW influenza vaccine coverage  NH resident mortality  NH HCW absenteeism

ACIP Recommendations Vaccinate NH residents Vaccinate NH HCWs Efficacy in preventing illness 30-40% National coverage estimates 66% Vaccinate NH HCWs Efficacy in preventing illness is 70-90% National coverage estimates 30%

Why are NH HCWs NOT getting vaccinated? NH HCW Knowledge, Attitudes, and Behaviors (KAB) Study on Influenza and Influenza Vaccine (Feb-March 2002)

NH HCW Characteristics 1020 HCWs from 30 NHs in Southern CA participated in study HCW vaccine coverage rates very low 34% for 2001-02 season 30% HCWs have no health insurance 46% HCWs have no sick leave benefits Ill HCWs likely to go to work Increases risk of disease transmission to others

Factors associated with HCWs NOT receiving influenza vaccine Unvaccinated HCWs Factors associated with HCWs NOT receiving influenza vaccine Beliefs and misconceptions Vaccine can cause the flu Vaccine is not very effective Influenza would be a mild illness to self Lack of easy access to vaccine             Vaccine not offered at work HCW too busy or forget to get vaccine Cost of vaccine

NH HCW Intervention Study Next Step… NH HCW Intervention Study Education Vaccine Day October

Education Intervention Comprehensive bilingual campaign Emphasized importance of vaccine Addressed common misconceptions Campaign components Educational handouts included with HCW paychecks Posters displayed in common areas 10-min video and detailed Q & A brochure for in-service

Vaccine Day Intervention Days designated for HCW vaccination at worksite Components Free vaccine offered to HCWs Vaccine Day reminder flier included with HCW paychecks Vaccine Day reminder posters displayed in common areas October

NH HCW Intervention Study 70 NHs from 2 Southern CA counties # NHs Education Vaccine Day Group A 25 — — Group B 15  — Group C 15 —  Group D 15   NHs = SNFs b/c thought less turnover of residents than ICFs & other facilities Total # of NHs in LAC = 432; OC = 80 Interventions implemented Oct-Nov 2002

HCW Influenza Vaccine Coverage Pre- and Post-Intervention (N = 4,309) % HCWs Vaccinated Pre-Int ’01-’02 29 28 33 37 Post-Int ’02-’03 27 34 45 53 Group A: Control B: Education C: Vaccine Day D: Ed + Vac Day OR* 1.00 1.31 2.28 3.54 95% CI -- 0.76 – 2.25 1.30 – 3.98 2.19 – 5.72 *Odds ratio adjusted for baseline vaccination status and clustering Group D HCWs were 3.5 times more likely to be vaccinated than Group A HCWs.

Summary Making influenza vaccine easily accessible through Vaccine Days was very effective in increasing NH HCW vaccination Education combined with Vaccine Days most effective Education alone was not effective

Issues to Consider Can this intervention be implemented on a larger scale? >1200 NHs in CA, >18,000 in US Is this sustainable? Without undue burden for NHs, LHDs Would NHs be willing (or able) to purchase vaccine for staff? Vaccine shortage and cost are issues

Acknowledgements California Dept. Health Services Infectious Diseases Branch Immunization Branch Los Angeles County Dept. of Health Services Immunization Program Public Health Training Unit Acute Communicable Disease Control Orange County Health Care Agency Epidemiology and Assessment Long Beach Dept. of Health and Human Services Epidemiology and Communicable Disease Pasadena Health Dept. Disease Prevention and Control Division Centers for Disease Control and Prevention Influenza Branch

Contact Information Akiko C. Kimura, MD Infectious Diseases Branch California Department of Health Services 19300 S. Hamilton Ave. Ste 140 Gardena, CA 90248 310-217-6907 310-217-6911 (fax) akimura@dhs.ca.gov