1. Influenza Vaccination in Employees, California General Acute Care Hospitals 2008-2009 Tricia McLendon, MPH Healthcare Associated Infections Program California Department of Public Health May 27, 2010

2. Influenza Significant cause of morbidity and mortality each year –Elderly, young children and persons with underlying medical conditions Healthcare personnel (HCP) are an important source of transmission –High rate of asymptomatic infection in HCP –HCP work when ill Worker shortages, compensation and dedication Source: Pavia AT. Mandate to protect patients from health care-associated influenza. Clin Infect Dis: 2010; 50:465-7.

3. Influenza Vaccination Most effective strategy for influenza prevention is annual vaccination Effectiveness varies –Patient characteristics –Match between circulating and vaccine strains Modestly effective –Elderly, infants, immunocompromised Highly effective –Healthy younger adults (many HCP) Source: Pavia AT. Mandate to protect patients from health care-associated influenza. Clin Infect Dis: 2010; 50:465-7.

4. Influenza Vaccination among HCP Simple, safe and cost effective Recommended and endorsed by –CDC ACIP –SHEA –NFID Healthy People 2010 target: 60% Proposed Healthy People 2020 target: 90% National rates remain low (~40%) Source: Pavia AT. Mandate to protect patients from health care-associated influenza. Clin Infect Dis: 2010; 50:465-7.

5. Influenza Vaccination among HCP Three strategies to increase compliance in HCP –Education and free, easily accessible vaccine –Mandatory signed declination –Mandatory vaccination with refusal enforced by respiratory masks, reassignment or termination Source: Pavia AT. Mandate to protect patients from health care-associated influenza. Clin Infect Dis: 2010; 50:465-7.

6. California Influenza Vaccination and Reporting Mandate in Acute Care Hospitals September 2006 –Free vaccine to all employees –Mandatory signed declination –January 2008 – mandatory report vaccination and declination rates to CDPH –No CDPH program for implementation December 2009 –HAI program at CDPH established

7. Objectives Report influenza vaccination rates in California general acute care hospitals for the 2008-2009 season Provide preliminary findings and interpretation Share limitations of data Discuss next steps and recommendations

8. Methods Licensed California general acute care hospitals Passive surveillance submitted via fax or email September 1, 2008 - March 31, 2009 Three different data collection forms –Total number of employees and HCP –Vaccinations and declinations in each group –Employment status in each group –Calculated employee specific vaccination and declination rates

9. Methods Overall mean vaccination and declination rates –Proportion of all employees in California that were vaccinated Facility-specific calculations for employees –Mean vaccination and declination rates –Frequency of employees with unknown vaccination status

10. Definitions On report forms –Employee Collected primary paycheck from the reporting facility Examples: administrative, dietary, facilities management staff –HCP Mutually exclusive from employees Examples: physicians, nurses, therapists, EMS personnel, pharmacists, lab personnel, contractual staff –Outreach

11. Definitions Hospital demographics collected from other data sources –Bed size –Rurality –Patient population: Pediatric and Mixed –Teaching status

12. Methods Exclusions –HCP –Outreach –Facilities that rescinded their data Licenses –Single vs. consolidated Non-reporters –25% contacted to verify no report sent

13. California Demographics Population38.1 million Number acute care hospitals Single license Consolidated license 432 338 (78%) 97 (22%), 46 licenses Licensed beds ICU NICU 71,964 6313 (9%) 3606 (5%) Number of discharges (2008)3.7 million Average length of stay (LOS)4.3 days Estimated patient-days (discharges x LOS) 15.9 million

14. Results Preliminary data 98 (29%) did not report Contacted 26 (25%) to verify that no report was sent –11 had submitted a report

15. Response Rate: Single License 338 (78%) general acute care hospitals with a single license –240 (71%) submitted vaccination report 98 (41%) at or above Healthy People 2010 target of 60%

16. Reporters n (%) Non-reporters n (%) p-value* Pediatric Mixed 9 (4) 231 (96) 3 (3) 95 (97) 0.76** 10-105 beds 106-242 beds 243+ beds 75 (31) 90 (38) 35 (36) 34 (35) 29 (30) 0.21** Rural Urban 44 (18) 196 (82) 17 (17) 81 (83) 0.83** Teaching Non-teaching 35 (15) 205 (85) 8 (8) 90 (92) 0.11** Hospital Demographics: Single License *Statistical significance: p<0.05; **Chi square

17. Vaccination Rates: Single License 240 hospitals –325,616 employees Overall rate = 55.5% (95% CI: 55.4-55.7) Facility-specific mean = 55.6% ± 14.1 –Minimum = 17.1% –Maximum = 92.0% 17.1% unknown status

18. Overall % (95% CI) Mean, % (SD)p-value* Pediatric Mixed 68.3 (67.5-69.1) 55.0 (54.8-55.2) 65.8 ± 6.7 53.4 ± 14.2 0.028** 10-105 beds 106-242 beds 243+ beds 53.8 (53.2-54.5) 57.2 (56.8-57.5) 55.1 (54.9-55.3) 55.3 ± 15.2 56.4 ± 14.3 55.3 ± 13.1 0.85*** Rural Urban 56.7 (55.9-57.4) 55.5 (55.3-55.6) 56.8 ± 14.7 55.4 ± 14.0 0.54** Teaching Non-teaching 55.7 (55.4-56.0) 55.4 (55.2-55.6) 57.4 ± 13.9 55.3 ± 14.2 0.42** Vaccination Rates by Hospital Demographics: Single License *Statistical significance: p<0.05;**Independent samples t-test; ***ANOVA

19. Declination Rates: Single License 240 hospitals –325,616 employees Overall rate = 27.4% (95% CI: 27.2-27.6) Facility-specific mean = 28.1% ± 14.1 –Minimum = 0% –Maximum = 64.3%

20. Overall % (95% CI) Mean, % (SD)p-value* Pediatric Mixed 24.3 (23.5-25.0) 27.5 (27.4-27.7) 19.8 ± 9.0 28.4 ± 14.1 0.073** 10-105 beds 106-242 beds 243+ beds 27.0 (26.4-27.6) 23.8 (23.5-24.0) 28.7 (28.5-28.9) 28.0 ± 14.9 26.1 ± 14.6 29.8 ± 12.7 0.25*** Rural Urban 27.8 (27.2-28.5) 27.4 (27.2-27.5) 26.9 ± 14.4 28.3 ± 14.0 0.54** Teaching Non-teaching 26.1 (25.8-26.3) 28.1 (27.9-28.3) 26.7 ± 12.0 28.3 ± 14.4 0.54** Declination Rates by Hospital Demographics: Single License *Statistical significance: p<0.05;**Independent samples t-test; ***ANOVA

21. Consolidated Licenses 46 consolidated licenses had 97 facilities –29 influenza vaccination report forms 27 reports (licenses) representing 57 facilities Two from 2 different facilities under same license –CDPH received report forms from 59/97 facilities under a consolidated license –Remaining 38 facilities under 18 licenses sent no report Contacting all facilities with consolidated licenses

22. Lessons Learned Significant misinterpretation of reporting definitions –Employees –HCP –Declination

23. Lessons Learned Data still provide important information –71% single-license hospitals reported influenza vaccination data for 2008-2009 1 out of 4 hospitals are not meeting reporting mandate –55.6% employee vaccination rate Not at Healthy People 2010 target of 60% Low vaccination rate, but slightly higher than other published results

24. Limitations Self-report bias –Facilities did no quality control or assurance of data –Hospitals with low rates less likely to report –Hospitals with high rates more likely to report Data quality –Multiple forms with conflicting data –Consolidated licenses Data completeness –Low response rate (71%) –HCP inclusion

25. Limitations Misclassification bias –Employees, HCP, declinations –17% of employees with unknown status Vaccinated elsewhere Medical exemption Not vaccinated –More information is needed

26. Recommendations Standardize definitions and report forms Identify barriers to reporting Provide data to IP grant personnel in field Identify best practices and barriers to vaccination Sample a subset of facilities Recommendations on mandatory vaccination to improve compliance

27. Recommendations Electronic reporting –Improve accuracy, decrease data entry –Facilitate communication NHSN Role –Does not permit reporting of aggregate data –Data transfer to NHSN not available from third party employee health software –CDC interested in pilot testing aggregate reporting over next two years

28. Acknowledgements CDPH HAI Program Staff Field IPs Hospitals: IPs and Employee Health

29. Single v Consolidated Facilities Total # facilities 432 Consolidated 97 facilities 46 licenses Single 338 facilities No report: 38 facilities 18 licenses 98 no report240 reported 29 reports 2 reports: 2 facilities 1 license 27 reports: 57 facilities 27 licenses

30. Response Rate: Consolidated License 94 (22%) general acute care hospitals associated with a consolidated license –41 licenses –XX (XX%) submitted vaccination report –XX (XX%) did not report

31. Hospital Demographics: Consolidated License Reporters n (%) Non-reporters n (%) p-value beds () Rural Urban () Pediatric Mixed () Teaching Non-teaching ()

32. Vaccination Rates: Consolidated License 94 hospitals – employees Overall rate = % (-) Median = % –Minimum = % –Maximum = % Mean = % ~% unknown status

33. Vaccination Rates by Hospital Demographics: Consolidated License Overall % (95% CI) Median % p-value 10-105 beds 106-242 beds 243+ beds (-) Rural Urban (-) Pediatric Adult (-) Teaching Non-teaching (-)

34. Declination Rates: Consolidated License 94 hospitals –employees Overall rate = % (-) Median = % –Minimum = % –Maximum = % Mean = %

35. Declination Rates by Hospital Demographics: Consolidated License Overall % (95% CI) Median % p-value beds (-) Rural Urban (-) Pediatric Adult (-) Teaching Non-teaching (-)