1. Promoting Flu vaccination for Health Care Workers
7th June 2011
Promoting Flu vaccination for Health Care Workers
Insert name of presentation on Master Slide
Dr Brendan W Mason Regional Epidemiologist

2. Why bother? Trivalent seasonal influenza vaccine should be offered to:
Health care staff directly involved in the care of patients.
Others involved directly in delivering health care such that they and vulnerable patients are at increased risk of exposure to seasonal influenza.
JANUARY UPDATE
UK Policy

3. Copyright Leah Millinship
Why bother?
“Getting employees vaccinated against the flu should be a corporate health priority as low uptake levels may put the people being cared for at risk.”
“NHS organisations should proactively encourage those directly involved in patient care to be vaccinated.”
LETTER FROM HEALTH MINISTER TO CHAIRS NHS HEALTH BOARDS 1st JULY 2010
Copyright Leah Millinship
Welsh Policy

4. Why bother? Prevent transmission of influenza from HCWs to patients
Patients at increased risk of acquiring influenza
Patients at increased risk of death or serious illness from influenza
Avoid disruption to services that provide patient care
Protect HCWs from influenza
Protect families HCWs from influenza
Intended outcome of policy

5. Why bother? How big is the problem? How effective is the intervention?
Health impact

6. Protecting patients: systematic review effectiveness
Influenza vaccination for HCWs who work with the elderly:
4 cluster randomised controlled trials (n = 8468)
over 60s in long term care facilities
Statistically significant reductions:
Influenza-like illness (ILI); GP consultations for ILI; all-cause mortality.
Non significant reductions:
Laboratory confirmed influenza; pneumonia; deaths from pneumonia.
Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD DOI: / CD pub3.
Evidence base

7. Protecting patients: systematic review effectiveness
Outcome
Number studies
Number patients
Relative Risk
95% CI
Influenza-like illness 3
7031
0.71
Confirmed Influenza 2
752
0.86
GP consultations ILI 1
2572
0.48
Pneumonia
1059
0.70
Death from pneumonia
4459
0.82
Death from all causes 4
8468
0.66
Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD DOI: / CD pub3.
Evidence base

8. Protecting patients: systematic review effectiveness
All cause mortality in patients in units where HCWs offered flu vaccine estimated to be 66% of level in units where HCWs not immunised
= One third reduction in deaths in patients in units where HCWs offered immunisation
95 % confidence interval estimate reduction in mortality 21% to 45% .
Outcome
Number studies
Number patients
Effect Size
95% CI
Influenza-like illness 3
7031
0.71
Confirmed Influenza 2
752
0.86
GP consultations ILI 1
2572
0.48
Pneumonia
1059
0.70
Death from pneumonia
4459
0.82
Death from all causes 4
8468
0.66
Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD DOI: / CD pub3

9. Protecting patients: systematic review effectiveness
Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD DOI: / CD pub3

10. Protecting patients: systematic review effectiveness
Over a 4-5 month period of high influenza activity:
13% (555/4258) patients died in units where HCW not immunised
9% (381/4210) patients died in units where HCW offered immunised
Absolute reduction in all cause mortality 4%
Highly statistically significant p=
Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. CochraneDatabase of Systematic Reviews 2010, Issue 2. Art. No.: CD DOI: / CD pub3

11. Protecting patients: economic evaluation
Most likely scenario
Vaccination HCW was cost saving
Saving of £12/vaccinee
Most pessimistic scenario
Cost £405/life-year gained
Burls A et al. Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006;24:4212–21.
Evidence base

12. Protecting patients: economic evaluation
Most likely scenario
Typical Welsh Health Board saving £175,000/year
Most pessimistic scenario
Cost £405/life-year gained
Cf. NICE cost effectiveness threshold £30 000 per quality adjusted life year (QALY) gained
Effective implementation should be a priority.
Burls A et al. Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006;24:4212–21.
Evidence base

13. Protecting HCWs: systematic review effectiveness
Influenza vaccines in healthy individuals aged 16 to 65 years:
40 randomised controlled trials (n = 70,000)
Statistically significant reductions:
Influenza-like illness (ILI); Laboratory confirmed influenza; working days lost; antibiotics prescribed.
Non significant reductions:
GP consultations; pneumonia; hospital admission.
Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD DOI: / CD pub4.
Evidence base

14. Protecting HCWs: systematic review effectiveness
Outcome
When circulating virus matches vaccine
Number studies
Number patients
Relative Risk
95% CI
Influenza-like illness 10
6984
0.70
Confirmed Influenza 8
11285
0.27
GP visits 1
1178
0.58
Hospital admission 2
2590
0.37
Pneumonia
1402
0.59
Working days lost 4
4263
Mean
-0.21
-0.36 to -0.05
Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD DOI: / CD pub4.
Evidence base

15. Protecting HCWs: systematic review effectiveness
73% reduction influenza in immunised HCWs
Immunised HCWs will on average take off 0.2 days less than unimmunised HCWs
Every 5 HCWs immunised will result in an extra day staff availability to provide clinical care
Outcome
When circulating virus matches vaccine
Number studies
Number patients
Relative Risk
95% CI
Influenza-like illness 10
6984
0.70
Confirmed Influenza 8
11285
0.27
GP visits 1
1178
0.58
Hospital admission 2
2590
0.37
Pneumonia
1402
0.59
Working days lost 4
4263
Mean
-0.21
-0.36 to -0.05
Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD DOI: / CD pub4.

16. Protecting HCWs: systematic review effectiveness
In general population healthy adults aged years when vaccine and circulating strain match:
4% of unvaccinated develop influenza
1% of vaccinated develop influenza
Absolute risk difference 3%
95% CI difference 2% to 5%
Risks infection HCW vs population unknown. Close contact with cases may mean risk acquiring infectinis higher and thus absolute benefit greater.
Jefferson T et al.Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD DOI: / CD pub4.

17. Conclusion In an ideal world more high quality research
Larger studies in more specific staff and/or patients groups
To demonstrate effects on less common outcomes and improve generaliseability
However, available evidence is consistent
Effective and cost effective for both staff and patients
Evidence base

18. How are we doing?
influenza immunisation uptake in Occupational Health

19. How are we doing?
Improving

20. How are we doing?
Improving, but some way to go.

21. How are we doing?
Uptake in different staff groups

22. Increase uptake in HCWs
What have you done?
What worked?
Share experience

23. Why are HCWs not immunised?
21 studies in 9 countries. Weighted score.
Hollmeyer FH et al. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine 2009;27:

24. Why are HCWs immunised? 21 studies in 9 countries. Weighted score.
Hollmeyer FH et al. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine 2009;27:

25. Intervention to increase uptake
Components
Definition
Examples
Education or promotion
Efforts to raise awareness and/or increase knowledge about influenza and influenza vaccine
Educational sessions
Educational materials
Events promoting vaccination
Incentives
Improved access to vaccine
Strategies to allow easier access to vaccination for HCWs
Mobile vaccine carts
Peer to peer vaccination
Additional clinics
Extended opening clinics
Legislation or regulation
Interventions involving changes in vaccination policy for HCWs
Employer policy
Declination forms
Mandatory immunisation
Measurement and feedback
Tracking of uptake rates in HCWs and dissemination of results
Regular reporting uptake to managers and/or HCWs
Role models
Activities that involve leaders and/or senior staff to encourage vaccination
Advocates and champions
Public support
Visible immunisation
Types of interventions
Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010;182(12):542-8.

26. Intervention to increase uptake
Not
exposed
Exposed
Change uptake
Education or Promotion
Dey et al.
Educational session & materials 6%
10%
+4%
Kimura et al.
Educational Video
30%
36%
+7%
Lemaitre et al.
32%
69%
+37%
Improved access
Free vaccine day
49%
+20%
Education + improved access
Educational Video & Free vaccine day
58%
+29%
Education + access +legislation + role model
Hayward et al.
Educational letter & out hours clinics & policy & training lead nurse advocates 5%
35%
+30%
Number are correct. Rounding errors! ( % % = % becomes 36%-30% = 7%)
Red statistically significant. All cluster RCTs
NOTE: Rounding errors! Red statistically significant
Randomised controlled trials: community
Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8.

27. Intervention to increase uptake
Not
exposed
Exposed
Change uptake
Education or Promotion
Doratotaj et al.
Letter from infectious disease department
38%
39%
+1%
Raffle ticket for $3000 vacation
42%
+4%
Letter from infectious disease department & Letter from infectious disease department
45%
+7%
Ohrt et al.
Letter from chief of infectious disease 8%
22%
+14%
Personalised phone call
11%
20%
+9%
Number are correct. Rounding errors! Red statistically significant. All small individual RCTs c per arm. Underpowered to detect intervention effect.
Randomised controlled trials: hospital
Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8.

28. Intervention to increase uptake
Before
After
Change uptake
Education + improved access
Tannenbaum et al.
Information sessions by doctors & informational memos + posters & extra clinics
10%
24%
+14%
Thomas et al.
Vaccination fair 8%
46%
+38%
Number are correct. Rounding errors! Red statistically significant.
Before and after trials: community
Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8.
Talbot R. Do declination statements increase health care workers influenza vaccination rates? CID 2009;49:773-9.

29. Intervention to increase uptake
Before
After
Change uptake
Education or Promotion
Zimmerman et al.
Incentive (lottery gift card)
34%
38%
+4%
Improved access
Mobile vaccine cart
39%
Sartor et al. 7%
32%
+25%
Cooper et al. 8%
49%
+41%
Education or Promotion+ improved access
Harbarth et al.
Educational meeting & mobile cart
23%
37%
+15%
Improved access + measurement feedback
Polgreen et al.
Vaccines at meetings & feedback uptake to directors
58%
61%
+3%
Legislation
Declination statement
54%
65%
+11%
Bertin et al.
55%
+17%
Ribner et al.
43%
+22%
Hagar
Mandatory vaccination
30%
98%
+68%
Babcock et al.
71%
99%
+28%
Intervention to increase uptake
Number are correct. Rounding errors! Red statistically significant.
Before and after trials: hospital
Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010:182(12);542-8.
Talbot R. Do declination statements increase health care workers influenza vaccination rates? CID 2009;49:773-9.

30. Mandatory vaccination
Introduced in US and Australia
? culturally more acceptable
US require immunisation for school attendances
In general not in keeping with UK approach
Immunity to hep B required for EPPs
A step too far for the UK?

31. Declination statement
Influenza Vaccine Declination Form
Health Board / NHS Trust Name: __________________________
You have given me the opportunity to be vaccinated with the influenza vaccine at no cost to myself.
I have received, read and understand information about the risks and benefits of the vaccine. I am eligible to receive the influenza vaccine BUT do not want to take it. I understand that by refusing the vaccine I may be putting MYSELF and my FAMILY, FRIEND, and PATIENTS at risk of getting influenza. I am aware that hospitalised patients are at increased risk of developing serious complications and death following influenza infection.
However, I decline the influenza vaccine at this time.
____________________________________
Employee’s Name (Print)
_____________________________________
Employee’s Signature
______________________________________
Date
Should be considered?

32. Conclusion Influenza vaccination protects HCWs and their patients.
Influenza vaccination is highly cost effective, and potentially cost saving for the NHS.
Multifaceted interventions are required to improve uptake in the NHS in Wales.
What are you going to do?

33. Copyright Leah Millinship
What are you going to do?
Copyright Leah Millinship
Organised efforts will succeed

34. References Intervention studies to increase uptake
Polgreen PM, Septimus EJ, Parry MF, et al. Relationship of influenza vaccination declination statements and influenza vaccination rates for healthcare workers in 22 US hospitals. Infect Control Hosp Epidemiol 2008; 29:675–7.
Bertin M, Scarpelli M, Proctor AW, et al. Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program. Am J Infect Control 2007; 35:33–7.
Buchta WG, Verdoon CA, Schultz GL. Effectiveness of declination statements in influenza vaccination programs for healthcare workers [abstract ]. In: Program and abstracts of the International
Commission on Occupational Health (ICOH) Conference on Health Care Worker Health/2007 State-of-the-Art Conference (Vancouver, British Columbia, Canada). International Commission on Occupational Health, 2007.
Ribner BS, Hall C, Steinberg JP, et al. Use of a mandatory declination form in a program for influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol 2008; 29:302–8.
Polgreen PM, Polgreen LA, Evans T, Helms C. A statewide system for improving influenza vaccination rates in hospital employees. Infect Control Hosp Epidemiol 2009; 30:474–8.
Sartor C, Tissot-Dupont H, Zandotti C, Martin F, Roques P, Drancourt M. Use of a mobile cart influenza program for vaccination of hospital employees. Infect Control Hosp Epidemiol 2004; 25:918–22.
Cooper E, O’Reilly M. A novel staff vaccination strategy. Infect Control Hosp Epidemiol 2002; 23:232–3.
Harbarth S, Siegrist CA, Schira JC, Wunderli W, Pittet D. Influenza immunization: improving compliance of healthcare workers. Infect Control Hosp Epidemiol 1998; 19:337–42.
Thomas DR, Winsted B, Koontz C. Improving neglected influenza vaccination among healthcare workers in long-term care. J Am Geriatr Soc 1993; 41:928–30.
Dey P, Halder S, Collins S, Benons L, Woodman C. Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial. J Public Health Med 2001; 23:346–8.
Doratotaj S, Macknin ML, Worley S. A novel approach to improve influenza vaccination rates among health care professionals: a prospective randomized controlled trial. Am J Infect Control 2008; 36:301–3.
Babcock HM et al. Mandatory influenza vaccination of health care workers:translating policy to practice. Clin Infect Dis 2010; 50: 459–64.
Hagar BA nd NIC National Immunization Conference: Mandatory influenza vaccination: the Virginia Mason Story. Available at:
Zimmerman RK, Nowalk MP, Lin CJ, et al. Factorial design for improving influenza vaccination among employees of a large health system. Infect Control Hosp Epidemiol 2009;30:691-7.
Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006;333:1241
Intervention studies to increase uptake