1. Influenza Vaccinations for Health Care Workers National Immunization Conference March 5-6, 2007 Richard Zimmerman MD MPH University of Pittsburgh School of Medicine Department of Family Medicine

2. Problem of Influenza Vaccination Among Health Care Workers (HCWs) Influenza causes 36,000 deaths annually in America Hospitals and health care centers are sites where the flu can be easily spread Each year, only 36-40% of health care workers receives a flu shot Infected HCWs place patients and colleagues at risk Absenteeism due to influenza can lead hospitals short staffed and unable to handle surge in influenza and pneumonia cases

3. ACIP RECOMMENDATIONS Health care workers should be vaccinated against influenza annually Efforts should be made to educate health care personnel regarding the benefits of vaccination and the potential health consequences of influenza illness for themselves and their patients Facilities that employ health care workers are strongly encouraged to provide vaccine to workers by using approaches that maximize immunization rates. All health care personnel should be provided convenient access to influenza vaccine at the work site free of charge, as part of employee health programs.

4. RISK IN HOSPITALS Many HCW work while sick, thus exposing patients and colleagues In one season, one quarter (23%) of HCWs had serologic evidence of influenza infection Most (59%) could not recall being sick, suggesting asymptomatic but contagious influenza JAMA 1999;281:908-13

5. BARRIERS TO VACCINATION According to the Literature Inconvenience Fear of needles Fear of side effects Low awareness of influenza severity Belief that influenza vaccine causes influenza Belief that HCWs not at risk Cost

6. Description: University of Pittsburgh Medical Center 40,000 employees 19 hospitals 165,000 annual admissions 3,000,000 annual outpatient visits

7. UPMC’S PREVIOUS EFFORTS Vaccination offered free of charge Peer vaccinations Flyers posted throughout the workplace In-house publication Employee health clinics

8. 2006 Survey of UPMC HCWs about Influenza Vaccine 2006 Survey of UPMC HCWs about Influenza Vaccine Survey mailed to 1200 UPMC HCW’s Participant payment $10 Minority HCW’s oversampled 740 responses Response rate – 62% Analyses ongoing Preliminary findings follow 58% reported receiving influenza vaccine. There was no difference in race, gender, educational level among those vaccinated compared with those unvaccinated

9. SURVEY RESULTS VARIABLENOT VACCINATED VACCINATED % agree % agree % agree % agree Person w/o flu vaccine will get flu 20.0 54.0 Flu shot prevents flu 31.2 62.3 Person w/o flu vaccine will get flu 20.0 54.0 Flu shot prevents flu 31.2 62.3 Flu mist prevents flu 26.9 55.8 My MD thinks I should get flu vaccine 47.3 83.7 Flu mist prevents flu 26.9 55.8 My MD thinks I should get flu vaccine 47.3 83.7 My co workers think I should get flu vaccine 42.2 71.9 My co workers think I should get flu vaccine 42.2 71.9 HCW with patient care has duty to get flu vaccine 39.4 85.6 HCW with patient care has duty to get flu vaccine 39.4 85.6

10. SURVEY RESULTS VARIABLE NOT VACCINATED VACCINATED % agree % agree % agree % agree Getting flu vaccine is wise 42.9 95.8 Getting flu vaccine is wise 42.9 95.8 Getting flu vaccine is too much trouble 42.2 5.5 House member gets flu, unvacc. 55.3 84.0 members also get flu Getting flu vaccine is too much trouble 42.2 5.5 House member gets flu, unvacc. 55.3 84.0 members also get flu Coworker gets flu, unvacc. 48.6 79.3 Coworker gets flu, unvacc. 48.6 79.3 coworkers also get flu Flu shot causes flu 31.7 8.6 Flu shot causes flu 31.7 8.6 Flu mist causes flu 31.2 12.5 Flu mist causes flu 31.2 12.5

11. SURVEY RESULTS The most frequently reported reason for receiving the influenza vaccine follow: –Protect oneself (93%), –Protecting others (67%). The biggest incentive to receive the influenza vaccine was convenience (70%) The most important reason for not being vaccinated against influenza was that it was not a priority (27%).

12. Fall 2006 Interventions in Response to Survey and Moderate Rates All sites – increased paper and electronic publicity –Minority physician as vaccine champion All sites – feedback to business units of low 2005 rates Interventions to be tested – incentives and convenience by on-site cart Cart staffed by EMTs and cost $50/hour Factorial design: both, one or no special interventions. Incentives varied by site: –food, lottery for $10 gift certificate, and/or lottery for paid time off, convenience via on-site mobile carts

13. UPMC Vaccination Methods Varies greatly by hospital tradition, size and set-up Employee health clinic Vaccination clinics in cafeteria or other convenient location Peer-to-peer vaccination on nursing units Mobile carts

14. Publicity Flyers posted in each institution Several articles published in the Extra!, a system-wide in-house publication Postings on the Infonet, a web-based information site accessible to all UPMC personnel

15. Interventions 490 hours of carts at $50/hr 460 gift certificates given away at rate of about 1 for every 10 vaccinees. 18,000 vaccines distributed in Fall 2006, compared to 11,000 in 2005

16. Vaccination Rates System transitioning to Occupational Heath Manager (OHM) software at all employee health sites OHM has individual record for each employee Feed from Human Resources PeopleSoft software of all employees Vaccines entered into OHM manually from written records (e.g., log from a vaccination clinic. Augmented by data from insurance company (1% only)

17. UPMC VACCINATION RATES Preliminary rates based in 2004 on general vaccine orders and in 2005-7 from OHM 2004-05: 15%* 2005-06: 31% with racial differences 2006-07: 45% * VACCINE SHORTAGE

18. UPMC Pre and Post Intervention Vaccination Rates

20. 2006-2007 INFLUENZA SEASON CARTS YESNO YESNO IYPRESBYTERIAN- FOOD +GCMCKEESPORT- GC NEMAGEE- FOOD + GCNORTHWESTFOOD/GC CSST. MARGARET PAID TIME OFFBEDFORD- GC E PASSAVANT- PTO NTI VNSOUTHSIDE BRADDOCK E O SHADYSIDE HORIZON CHILDREN’S WPIC CHILDREN’S WPIC GC= Lottery for Gift Cards

21. UPMC Vaccination Rates by Factorial Design CARTS YESNO YESNO IYPRESBYTERIAN 65.2%MCKEESPORT 46.7% NEMAGEE 40.5% NORTHWEST 48.4% CSST. MARGARET 52.3% BEDFORD 57.2% E PASSAVANT 42.0% NTI VNSOUTHSIDE 38.5% BRADDOCK 40.1% E O SHADYSIDE 43.0% HORIZON 33.3% CHILDREN’S 43.3% WPIC N/A CHILDREN’S 43.3% WPIC N/A

22. Increase in UPMC Vaccination Rates by Factorial Design CARTS YESNO YESNO IYPRESBYTERIAN 17.3MCKEESPORT 12.9 NEMAGEE 6.8 NORTHWEST (5.4) CSST. MARGARET 11.2 BEDFORD N/A E PASSAVANT (1.3) NTI VNSOUTHSIDE 5.0 BRADDOCK 8.5 E O SHADYSIDE 9.0 HORIZON (7.0) CHILDREN’S N/A WPIC N/A CHILDREN’S N/A WPIC N/A

23. Limitations Data analyses preliminary and need sophisticated analyses due to cluster design Bleed between units as some hospitals close together Do not have vaccines that HCWs purchased at non-traditional providers Need significance testing

24. CONCLUSION HCW influenza vaccination rates can be significantly raised through appropriate interventions These include education and publicity, offering no-cost vaccinations at convenient times and locations, and a strong commitment from upper-level executives and unit managers

25. Influenza Vaccination of Health Care Workers is a Major Patient Safety Issue Two trials in long-term care facilities found HCW vaccination decreased patient fatalities Lancet 2000;355:93-7; JID 1997;175:1-6 CDC, Advisory Committee on Immunization Practices, & Hospital Infection Control Practices Advisory Committee state HCW vaccination is a measure of patient safety MMWR 2006;55(RR-2):2 Ethical imperative “First do no harm: ensuring that health care workers vaccinate and are vaccinated.” Infection Control and Hospital Epidemiology 2003;24:799-800 Influenza vaccination of HCWs is called “The Next Battleground for Patient Safety” Infection Control and Hospital Epidemiology 2005;26:850-1. “The Next Battleground for Patient Safety” Infection Control and Hospital Epidemiology 2005;26:850-1.