1. Influenza Vaccinations for Health Care Workers National Immunization Conference March 17-20, 2008 Richard Zimmerman MD MPH University of Pittsburgh School of Medicine Department of Family Medicine

2. Influenza Vaccination of Health Care Workers in a Diverse Hospital Network This study was approved by the Quality Assurance Committee of the University of Pittsburgh Medical Center (UPMC) This study was supported by the Centers for Disease Control and Prevention, Grant No. IP000064-02. Its contents are the responsibility of the authors and do not necessarily reflect the official views of the CDC.

3. Improving Health Care Worker Influenza Vaccination Rates in a Diverse Hospital Network Richard Kent Zimmerman, MD, MPH, Mary Patricia Nowalk, PhD, RD, Chyongchiou J. Lin, PhD, Dwight E. Fox, DMD, Mahlon Raymund, PhD, Jay D. Harper, MD, Mark D. Tanis, RN, Bayo C. Willis, MPH From the Dept. of Family Medicine and Clinical Epidemiology (RKZ, MPN, CJL, DEF, MR) the Department of Radiation Oncology (CJL), University of Pittsburgh School of Medicine, the Dept. of Behavioral and Community Health Sciences (RKZ) and the Dept. of Health Policy and Management (CJL), University of Pittsburgh Graduate School of Public Health, the University of Pittsburgh Medical Center Dept. of Employee Health (JDH, MDT) and the Centers for Disease Control and Prevention (BCW).

4. 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 Infected HCWs place patients and colleagues at risk Absenteeism due to influenza can leave hospitals short staffed and unable to handle surge in influenza and pneumonia cases

5. Response: ACIP/CDC Recommendations HCWs should be vaccinated against influenza annually Efforts should be made to educate HCWs about the benefits of vaccination and the potential health consequences of influenza illness for themselves and their patients Facilities are strongly encouraged to provide vaccine to workers by using approaches that maximize immunization rates. HCWs should be provided convenient access to influenza vaccine at the work site free of charge, as part of employee health. However, only 33-42% of HCWs are vaccinated annually

6. Why Not? Barriers to Vaccination According to the Literature Inconvenience Fear of needles Fear of side effects Belief that influenza vaccine causes influenza Low awareness of influenza severity Belief that HCWs not at risk CostTime

7. Our Institution’s Previous Efforts Vaccination offered free of charge Peer vaccinations on units Flyers posted throughout the workplace In-house publications Employee health vaccination clinics

8. Our Institution’s 2005-06 HCW Survey 6 UPMC Hospitals surveyed Vaccinated and unvaccinated HCW’s differ in beliefs Most frequently cited reason to be vaccinated was to protect oneself Most important incentive was convenience Most important reason for lack of vaccination was that it was not viewed as a priority Findings were used to plan 2006-2007 interventions

9. Description: University of Pittsburgh Medical Center 43,000 employees 19 hospitals 167,000 annual admissions 3,000,000 annual outpatient visits

10. 2006-2007 Interventions: All Hospitals Publicity: - Posters, Infonet, Extra! newsletter - Posters, Infonet, Extra! newsletter Peer vaccinations on units Peer vaccinations on units Employee vaccination rates for each institution sent to its respective CEO

11. 2006-2007 Interventions: Selected Sites Mobile flu carts on units Incentives: - Gift cards awarded through lottery: 1 in 10 chance of receiving gift card - Food available at flu clinics - Food available at flu clinics - Paid time off awarded by lottery at 2 hospitals - Paid time off awarded by lottery at 2 hospitals - Unit pizza party for highest vaccination rate at one hospital - Unit pizza party for highest vaccination rate at one hospital

12. Factorial Design for Hospital Interventions MOBILE VACCINATION CARTS MOBILE VACCINATION CARTS INCENTIVES YESNO Hospital 7 (non-community urban)*# Hospital 3 (community urban)# Hospital 7 (non-community urban)*# Hospital 3 (community urban)# YES Hospital 4 (non-community urban)*# Hospital 5 (community rural)*# Hospital 9 (community suburban) + Hospital 6 (community suburban)! Hospital 9 (community suburban) + Hospital 6 (community suburban)! Hospital 11(non-community urban)*% Hospital 11(non-community urban)*% ___________________________________________________________________ ___________________________________________________________________ Hospital 8 (non-community urban) Hospital 1 (community urban) Hospital 8 (non-community urban) Hospital 1 (community urban)NO Hospital 10 (community urban) Hospital 2 (community rural) Hospital 10 (community urban) Hospital 2 (community rural) _____________________________________________________________________ _____________________________________________________________________ * Food at flu clinics * Food at flu clinics # Gift card lottery for vaccinees # Gift card lottery for vaccinees ! Paid time off lottery for vaccinees ! Paid time off lottery for vaccinees % Unit party for highest percent vaccination % Unit party for highest percent vaccination

13. DATABASE Occupational Health Manager (OHM) software- populated from Human Resources’ PeopleSoft database All vaccines given recorded in OHM All employees of UPMC employed from Oct. 1 to Dec. 31 during 2005 and 2006 were included Insurance claims for flu vaccinations given outside the system were added, amounting to about 1%

14. Statistical Analyses Clustered samples within each hospital Specified that primary study units were hospitals SAS statistical software version 9.1(SAS Institute Inc., Research Triangle, NC) SAS callable SUDAAN 9.0 statistical package (Research Triangle Park, NC: Research Triangle Institute)

15. RESULTS N = 26,449 Pre-intervention rate: 32.4% Post-intervention rate: 39.6% P <.001 Z test two tailed

16. RATES BY HOSPITAL Hospital ID%Vacc. 2005-06%Vacc. 2006-07 Incentives & carts 731.338.3* 432.937.0* 939.849.3* Incentives - no carts 331.844.1* 551.755.0* 643.240.3* 1117.035.7* Carts - no incentives 831.539.3* 1029.535.1* No carts - no incentives 129.136.0* 236.338.0* * P <.05

17. DEGREE OF PATIENT CONTACT PRE-INTERVENTION POST-INTER. Direct contact31.1%39.5% Indirect 31.5%38.4% No contact 35.3%40.4% <.05 P <.05

18. Effect of Interventions on Different Groups of Health Care Workers I Job category Year 1 (2005-06) % Vacc. Intervent. Publicity + Education +… Year 2 (2006-07) % Vacc. Diff. Direct Patient Contact 31.1 31.6 30.2 31.6 Both Incentives Carts ------- * P <.05 41.4 38.4 39.0 34.5 10.3 * 6.8 * 8.8 * 2.9

19. Effect of Interventions on Different Groups of Health Care Workers II Job category Year 1 (2005-06) % Vacc. Intervention s: Publicity + Education +… Year 2 (2006-7) % Vacc. Diff. Indirect Patient Contact 32.032.828.330.4BothIncentivesCarts ------- ------- * p <.05 * p <.0538.043.233.733.4 6.0 * 10.4 * 5.4 * 3.0

20. Effect of Interventions on Different Groups of Health Care Workers III Job category Year 1 (2005-06) % Vacc. Interventions : Publicity + Education +… Year 2 (2006-7) % Vacc. Diff. Business/ Admin. 34.933.538.343.1BothIncentivesCarts ------- ------- * P <.05 * P <.0537.646.143.351.3 2.7 * 12.6 * 5.0 8.2 *

21. Effect of Interventions on HCW Influenza Vaccination Rates with Direct Patient Contact from Logistic Regression I Variables OR OR (95% CI) (95% CI) Age > 50; ref. = 50; ref. = <50 years 1.88 1.88 (1.72-2.05) (1.72-2.05) Female, ref. = male 1.04 1.04 (0.93-1.16) (0.93-1.16) White, ref. = non-white 1.76 1.76 (1.55-2.00) (1.55-2.00) Community hospital, ref. = non-community hospital 1.33 1.33 (1.04-1.70) (1.04-1.70)

22. Effect of Interventions on HCW Influenza Vaccination Rates with Direct Patient Contact from Logistic Regression II 1.47 1.47 (1.02-2.10) (1.02-2.10) Intervention: Incentives no, Carts yes* 1.22 1.22 (0.97-1.55) (0.97-1.55) Intervention: Incentives yes, Carts no* 1.63 1.63 (1.31-2.03) (1.31-2.03) Intervention: Incentives yes, Carts yes* 1.48 1.48 (1.21-1.80) (1.21-1.80) Intervention year, ref. = baseline OR OR (95% CI) (95% CI) Variables *Ref.=publicity and education only

23. Summary Multimodal interventions including incentives and carts increase rates Look at job categories as variable in planning incentives Specific interventions work better with different groups

24. Incentives Vs. Convenience Incentives are superior when applied to HCWs with indirect patient contact Mobile carts (convenience) are most effective for HCWs with direct patient contact. Incentives are only effective with this group when used in combination with carts

25. RECOMMENDATIONS Convenience (carts) Meaningful incentives Emphasis on education Publicity in a variety of forms Free vaccine Offer variety in times and delivery systems Accountability

26. WHAT’S NEXT? Mandatory vaccination for HCW’s ? Declination statements ? Mandatory reporting of HCW vaccination status – probably next for us Required training and test – now implemented in part of UPMC (UPP)

27. Strengths First study with factorial design Uses multiple, diverse hospitals Common electronic vaccine registry

28. Limitations Crossover between units as some hospitals are close together Do not have record of all vaccinations that HCWs received at non-traditional providers

29. 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

30. 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: 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” “The Next Battleground for Patient Safety” Infection Control and Hospital Epidemiology 2005;26:850-1. Infection Control and Hospital Epidemiology 2005;26:850-1.

31. CONCLUSION HCW influenza vaccination rates can be significantly raised through appropriate interventions These include mobile carts and incentives Should be applied based on type of HCW

32. UPP Required Training Required of UPP Required to pass 3 question test on materials

33. A “Call to Action” issued for Influenza Vaccination of Health Care Workers American College of Physicians American Academy of Family Physicians American Academy of Pediatrics American College of Occupational and Environmental Medicine American College of Occupational and Environmental Medicine American Hospital Association American Medical Association American Nurses Association American Society of Health-System Pharmacists National Medical Association Centers for Disease Control and Prevention Association for Professionals in Infection Control and Epidemiology, Inc. Joint Commission on Accreditation of Healthcare Organizations

34. AJPH 1993; 83:1712-16 Influenza infections are common as found by active surveillance in the Tecumseh Study

35. Influenza is highly contagious as seen by a 72% attack rate in exposed persons in a 4.5 hour plane flight Communicability is highest 1-2 days before symptoms to 4-5 days after onset

36. Influenza Outbreak in a Hospital Unit A patient infected roommates and health care workers (HCWs) who in turn spread it to others A total of 15/29 patients & 15/33 HCWs were infected J Clin Invest 38:199-212

37. Risks of Spread in Hospitals In 1 season, a quarter (23%) of HCWs had serologic evidence of influenza infection. However, most (59%) could not recall being sick, suggesting asymptomatic “flu.” JAMA 1999;281:908-13 Those with few or mild symptoms can spread influenza to patients, other HCWs, and their families. Many Health Care Workers (HCWs) come to work while sick, thus exposing patients and colleagues 1918 Influenza Pandemic - Army Hospital

38. Influenza Fatality Rates in US (per 100,000) Influenza fatality rates begin to rise at age 45 and are highest in those with high risk conditions. Such conditions include COPD, DM, & CHF, which are common causes of hospitalization 36,000 deaths due to influenza occur annually JAMA 2004;292:1333-40 Therefore, health care worker vaccination is important for our high risk patients who could die from influenza if infected. Arch IM 1982:142:87

39. Influenza Vaccine Types 1) Inactivated influenza vaccine (shot) –Preparations used recently have fewer reactions than older preparations. –Older whole cell vaccines are off the market; they had higher reaction rates –When vaccine and circulating strains are well matched, efficacy is 70%-90% in healthy persons <65 years of age –Serious adverse events are rare: e.g., anaphylaxis in those severely allergic to eggs 2) Cold adapted influenza vaccine (nasal spray) is available for those who do not want shots

40. Benefit of Inactivated Influenza Vaccine In Healthy Adults Aged 18-64 NEJM 1995; 333:889-893 Reduces colds, sick days and doctor visits

41. Safety of Inactivated Influenza Vaccine One placebo controlled trial in the elderly found the only difference between vaccine recipients and placebo recipients was: –20% of vaccinees compared to 5% of placebo recipients had a sore arm (P <.001) JAMA 1990;264:1140 A multi center, randomized, double blind, placebo-controlled cross-over trial in 2032 asthmatics found –No change in respiratory function (see next slide) –Mild increase in achiness

42. * p<0.001 NEJM 2001; 345:1529-36 Safety of Inactivated Influenza Vaccine in Asthmatics A multi center, randomized, double blind, placebo-controlled trial in 2032 asthmatics found no change in respiratory function

43. Problem - Low Health Care Worker (HCW) Vaccination Rates Risks of low rates –Employee’s health –Health of employee’s family –Absenteeism and inability to staff units –Patient health, particularly if have underlying chronic illnesses

44. Benefits from Influenza Vaccination of Health Care Workers 0 10 20 30 40 50 60 70 80 90 100 Percent Reduction 88 28 41 39 Infection Control & Hosp Epidemiology 2005:26:883

45. 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.” JCAHO requires hospitals to calculate HCW vaccination rates and study reasons for non-participation Influenza vaccination of HCWs is called “The Next Battleground for Patient Safety” “The Next Battleground for Patient Safety” Infection Control and Hospital Epidemiology 2005;26:850-1. Infection Control and Hospital Epidemiology 2005;26:850-1.

46. Reasons for HCW Influenza Vaccination Protect oneself –Reduces sick days by 28% Protect one’s family and friends Keep absenteeism low during outbreaks so hospitals can be staffed to help the sick Protect patients –Reduces mortality by about 40% in 2 studies in long-term care facilities Keep the ethical code of “do no harm”