1. Improving Influenza Vaccine Coverage Levels among Nursing Home Health Care Workers
Akiko C. Kimura, MD
Jeffrey Higa, MPH
Christine Nguyen, MPH
California Department of Health Services
Infectious Diseases Branch

2. Overview Background/scope of the problem
Knowledge, attitudes, and behaviors study of nursing home (NH) health care workers (HCWs)
NH HCW intervention study

3. Background Annual influenza epidemics NH residents vulnerable
>100,000 hospitalizations, >30,000 deaths
>90% of deaths occur in those ≥65 yrs old
NH residents vulnerable
Due to:
underlying medical conditions
living in close proximity
contact with a range of caregivers
60% infected during outbreaks, 25% require hospitalization

4. California Elderly & NHs
CA elderly (≥65 years)
2000: 3.6 million (10% CA pop.)
2050: 9.9 million (18% CA pop.)
>1200 NHs in CA (2003)
2000: 100,000 residents
2050: 175,000 residents

5. NH HCWs
Source of NH influenza outbreaks even with high resident vaccination rates
Higher NH HCW influenza vaccine coverage
 NH resident mortality
 NH HCW absenteeism

6. ACIP Recommendations Vaccinate NH residents Vaccinate NH HCWs
Efficacy in preventing illness 30-40%
National coverage estimates 66%
Vaccinate NH HCWs
Efficacy in preventing illness is 70-90%
National coverage estimates 30%

7. Why are NH HCWs NOT getting vaccinated?
NH HCW Knowledge, Attitudes, and Behaviors (KAB) Study on Influenza and Influenza Vaccine (Feb-March 2002)

8. NH HCW Characteristics
1020 HCWs from 30 NHs in Southern CA participated in study
HCW vaccine coverage rates very low
34% for season
30% HCWs have no health insurance
46% HCWs have no sick leave benefits
Ill HCWs likely to go to work
Increases risk of disease transmission to others

9. Factors associated with HCWs NOT receiving influenza vaccine
Unvaccinated HCWs
Factors associated with HCWs NOT receiving influenza vaccine
Beliefs and misconceptions
Vaccine can cause the flu
Vaccine is not very effective
Influenza would be a mild illness to self
Lack of easy access to vaccine            
Vaccine not offered at work
HCW too busy or forget to get vaccine
Cost of vaccine

10. NH HCW Intervention Study
Next Step…
NH HCW Intervention Study
Education
Vaccine Day
October

11. Education Intervention
Comprehensive bilingual campaign
Emphasized importance of vaccine
Addressed common misconceptions
Campaign components
Educational handouts included with HCW paychecks
Posters displayed in common areas
10-min video and detailed Q & A brochure for in-service

13. Vaccine Day Intervention
Days designated for HCW vaccination at worksite
Components
Free vaccine offered to HCWs
Vaccine Day reminder flier included with HCW paychecks
Vaccine Day reminder posters displayed in common areas
October

15. NH HCW Intervention Study
70 NHs from 2 Southern CA counties
# NHs Education Vaccine Day
Group A — —
Group B  —
Group C — 
Group D  
NHs = SNFs b/c thought less turnover of residents than ICFs & other facilities
Total # of NHs in LAC = 432; OC = 80
Interventions implemented Oct-Nov 2002

16. HCW Influenza Vaccine Coverage Pre- and Post-Intervention (N = 4,309)
% HCWs Vaccinated
Pre-Int ’01-’02 29 28 33 37
Post-Int ’02-’03 27 34 45 53
Group
A: Control
B: Education
C: Vaccine Day
D: Ed + Vac Day
OR*
1.00
1.31
2.28
3.54
95% CI --
0.76 – 2.25
1.30 – 3.98
2.19 – 5.72
*Odds ratio adjusted for baseline vaccination status and clustering
Group D HCWs were 3.5 times more likely to be vaccinated than Group A HCWs.

17. Summary
Making influenza vaccine easily accessible through Vaccine Days was very effective in increasing NH HCW vaccination
Education combined with Vaccine Days most effective
Education alone was not effective

18. Issues to Consider
Can this intervention be implemented on a larger scale?
>1200 NHs in CA, >18,000 in US
Is this sustainable?
Without undue burden for NHs, LHDs
Would NHs be willing (or able) to purchase vaccine for staff?
Vaccine shortage and cost are issues

19. Acknowledgements California Dept. Health Services
Infectious Diseases Branch
Immunization Branch
Los Angeles County Dept. of Health Services
Immunization Program
Public Health Training Unit
Acute Communicable Disease Control
Orange County Health Care Agency
Epidemiology and Assessment
Long Beach Dept. of Health and Human Services
Epidemiology and Communicable Disease
Pasadena Health Dept.
Disease Prevention and Control Division
Centers for Disease Control and Prevention
Influenza Branch

20. Contact Information
Akiko C. Kimura, MD
Infectious Diseases Branch
California Department of Health Services
19300 S. Hamilton Ave. Ste 140
Gardena, CA
(fax)