1. Mark H. Sawyer, Michelle Dzulynsky, Christina Hawley, Naomi Katzir, Kathy Holcomb, Michelle DeGuire, Wendy Wang, Michael Peddecord, Kathe Gustafson, Anne Hassidim, Adrienne Collins-Yancey County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch Can You Build a Better Mousetrap? What’s new with healthcare worker influenza immunization in San Diego

2. Objectives List the common myths among healthcare workers regarding influenza immunization Describe interventions used by hospitals to overcome these myths and promote influenza immunization for staff Discuss barriers faced by hospitals to improving healthcare worker influenza immunization rates

3. SDHIIP Background Two year study funded by the CDC (9/05-9/07) 14 hospitals participated in study 17 currently involved 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

4. Myths Myths HCWs commonly believe: I never get the flu, I’m healthy Vaccine has side effects I got sick from the vaccine last time Vaccine doesn’t protect against the flu

5. Where the Employees Were Vaccinated (All Unit-Based Respondents) n= 349

6. Vaccination Method 2005-2006 Data

7. Vaccination Method 2006-2007 Data

8. Hospital-based HCW RDD Survey results 2006 Ever received flu vaccine85.9% For those who have never received vaccine, why not? –Not in priority group/healthy44.4% –Vaccine side effects19.4% –Vaccine doesn’t work13.9% Had to pay for vaccine7.1% Received nasal vaccine2.0% Offered nasal vaccine8.2% Received vaccine at workplace87.3%

9. Hospital Interventions Education programs –PowerPoint Training Modules –SDHIIP Presentations Declination statements Procedures to ensure compliance

10. Hospital Interventions – Training Modules UCSD Medical Center Mandatory Training –3316 employees completed training 1983 received vaccine from UCSD 510 received it elsewhere 783 declined vaccination –Most common reasons for declining vaccine I never get the flu I don’t like needles I will get the flu from the vaccine I stay home when I’m sick so I won’t spread it County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch

11. Hospital Interventions – Training Modules Sharp Healthcare training included a declination, submitted upon completion of training How to Prevent this Highly Infectious Respiratory Disease Influenza Vaccination for Sharp Health Care Workers

12. Summary of 2007-08 influenza (flu) information for Sharp employees  I understand that flu is an annual respiratory illness with symptoms of fever, cough, achiness, and fatigue. Flu is transmitted from person to person by large droplets expelled into the air or by hands/objects contaminated with the virus that touch the face (nose, mouth, eyes). Flu is associated with 36,000 deaths each year in the U.S. Flu can be best prevented by annual vaccination which is available at no cost to Sharp employees on site each year through roaming carts/ buckets, employee flu clinics, and on a walk-in basis in EOHD.  Additionally I understand that washing my hands, covering my mouth/nose when coughing/sneezing, avoiding touching my face, and staying home when I am ill can also help protect myself, patients, family and others from the flu and other illnesses.

13. Hospital Interventions – Training Module IT at Palomar-Pomerado Health developed an educational ‘movie’ for their training Will be mandated next year Did not track training compliance this year County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch

15. Declination Statements All hospitals implemented declination statements during the 2007-2008 season because of California legislation passed in 2006 Variety of statements used Variable enforcement with compliance County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch

16. Declination Statements SB 739 County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch 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.”

17. Declination ReasonsPlease check all that apply a) I don’t believe that the vaccine will work b) I am concerned about side effects c) I am afraid of injections d) I received the vaccine elsewhere—please note where e) Other All individuals subject to the HR Influenza Vaccination Policy are required to sign this form when declining the flu vaccine. I have been offered the influenza vaccination at no charge by the Kaiser Permanente entity that employs me. I have been provided with educational materials about the influenza vaccination and the potential risk to myself and others if I decline vaccination. I have received and reviewed these materials and I hereby decline the vaccine for the reasons provided below. I understand that if I change my mind, I may obtain the vaccine at any time during the year, at no charge, as long as Kaiser Permanente still has a supply of the vaccine. Declination Example from Kaiser Permanente Hospital

18. SCRIPPS MEMORIAL HOSPITAL – LA JOLLA DECLINATION OF ANNUAL INFLUENZA VACCINATION I understand that due to my occupational exposure, I may be at risk of acquiring influenza infection. In addition, I may spread influenza to my patients and other healthcare workers, and my family, even if I have no symptoms. This can result in serious infection, particularly in persons at high risk for influenza complications. I have received education about the effectiveness of influenza vaccination as well as the adverse events. I have also been given the opportunity to be vaccinated with influenza vaccine, at no charge to myself. However, I decline influenza vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring influenza, potentially resulting in transmission to my patients. If in the future I want to be vaccinated with influenza vaccine, I can receive the vaccine at no charge to me. _________________________________________________________ SignatureDate Please share your reason(s) for declination:  I prefer not to get the vaccine  I received the flu vaccine elsewhere  I am not medically eligible for flu shot  Other reasons:_______________________

19. Hospital Interventions Declination/Consent Compliance ’07-’08

20. Hospital Interventions Declination Statements Many hospitals encountered resistance with implementation –Questioned regulations, needed to show SB 739 Discussion with key stakeholders, unions –HIPAA and confidentiality concerns Wording had to be positive, encouraged education and allowed option for later vaccination –Employees were educated on benefits of vaccine, potential for becoming ill and transmitting virus to others County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch

21. Hospital Interventions Policies for Unimmunized HCW’s None Unimmunized employees required to wear a mask during influenza season Unimmunized/non-compliant employees placed on administrative leave during influenza season until they are compliant – vaccinated or signed declination Unimmunized/non-compliant employees terminated if not compliant by deadline County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch

22. Tdap Vaccine 7/14 SDHIIP hospitals are currently offering Tdap vaccine primarily to their “high-risk” HCW population: ED, ICU, NICU, Maternal/Child Health, and respiratory departments 7/14 are offering Tdap to all of their HCWs –New hires, PPD checks None have promotional efforts similar to influenza for Tdap

23. Tdap Vaccine Kaiser Permanente offered Tdap vaccine on their mobile carts with influenza vaccine –Vaccinator had list of all employees and their vaccination status, if employee was interested in getting Tdap, status was checked on list Other hospitals had problems with mobilizing Tdap –Difficulty with access to employee data

24. Acknowledgements San Diego Immunization Branch staff San Diego Public Health Officer –Wilma Wooten, MD, MPH SDHIIP Contact Information: –Principal Investigator: Mark Sawyer, MD mark.sawyer@sdcounty.ca.gov –Project Coordinator: Michelle Dzulynsky michelle.dzulynsky@sdcounty.ca.gov Thank you for your support and contribution. County of San Diego ● Health and Human Services Agency ● Public Health Services ● Immunization Branch