1. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch You want me to sign what? Implementation of influenza immunization declination statements among San Diego hospital-based healthcare workers in 2007-2008 Mark H. Sawyer, Michelle Dzulynsky, Michelle DeGuire, K. Michael Peddecord, Wenrong Wang, Naomi Katzir, Karen Waters-Montijo

2. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Objectives Describe the efforts among San Diego hospitals to obtain declination statements when healthcare workers refused influenza vaccine Describe the impact of a state law requiring influenza vaccine declination statements List some elements used in hospital-based influenza vaccine declination statements

3. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch SDHIIP Background Started as a study funded by the CDC (9/05-9/07) 17 hospitals currently involved in partnership Collaborators: – San Diego County HHSA, – UCSD San Diego Immunization Partnership – San Diego Immunization Coalition (formerly I-3) – Community Health Improvement Partners (CHIP) – San Diego Hospital Association – San Diego County Medical Association

4. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch SDHIIP Participating Hospitals Children’s Hospital; Kaiser Permanente; Navy Medical Center, San Diego; Palomar- Pomerado Healthcare; Tri-City Medical Center; UCSD Medical Center; Scripps : Green, La Jolla, Chula Vista, and San Diego Hospitals (Mercy), Sharp : Chula Vista, Coronado, Grossmont, Mary Birch, and Memorial Hospitals

5. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Healthcare Worker Influenza Vaccine Myths I’m not in the group for whom influenza vaccine is recommended I never get influenza, I’m healthy Influenza vaccine has side effects, I will get the flu from the vaccine Vaccine doesn’t protect against influenza I can’t get the nasal influenza vaccine because I’m a healthcare worker

6. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Hospital Interventions Declination Statements SB 739 States that each general acute care hospital shall take the following actions (by July 1, 2007): –“Annually offer onsite influenza vaccinations, if available, to all hospital employees at no cost to the employee. Each general acute care hospital shall require employees to be vaccinated, or if the employee elects not to be vaccinated, to declare in writing that he or she has declined the vaccination.” Signed 09/28/2006 by Governor of California

7. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Hospital Interventions Declination Statements All hospitals implemented declination statements during the 2007-2008 season because of California legislation passed in 2006 Variety of statements used Incomplete tracking systems in some hospitals. None using our regional immunization registry. Variable enforcement with compliance

8. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Mandatory trainings Education programs –PowerPoint Training Modules Several hospitals attached an ‘anonymous’ declination Employees could sign the declination upon completion of manual, print it out and submit to EH Declination statements Procedures to ensure compliance

9. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch

10. Influenza vaccination coverage rates in healthcare workers flu seasons.

11. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Compliance With Declination Statements If Not Vaccinated n=521 (2007) n=213 (2008)

12. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Repercussions? n=40

13. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Knowledge of Declination Statement Law p<0.05

14. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Hospital Policies for Unimmunized/Noncompliant HCW’s None Unimmunized employees required to wear a mask during influenza season Unimmunized employees placed on administrative leave during influenza season Noncompliant employees terminated?

15. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Do Declination Statements Make a Difference???

16. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Conclusions Declination statement compliance less than 100% despite state law Vast majority of employees willing to sign declinations if they were not going to be immunized Knowledge of declination statement law associated with greater likelihood of immunization Highly variable policies with regard to unprotected HCW’s in the workplace

17. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Acknowledgements Coauthors: Michelle Dzulynsky; Michelle Deguire, MSW, MPH; Naomi Katzir, Wenrong Wang, MPH; K. Michael Peddecord, DrPH; Karen Waters-Montijo, MPH Wilma Wooten, MD, MPHAdrienne Yancey, MPH Public Health Officer Assistant Deputy Director County of San Diego San Diego Immunization Branch staff