1. S Carrots and Sticks: Influenza Vaccination of Healthcare Workers Susan E Coffin, MD, MPH Children’s Hospital of Philadelphia July, 2011

2. Overview Rationale behind HCW influenza vaccination Implementing a mandatory flu vaccination program at CHOP Impact of mandate HCW attitudes Nosocomial influenza rates

3. HCW Flu Vaccination: background Vaccination of health care workers (HCW) decreases… ▫Healthcare-associated influenza infection ▫HCW absenteeism ▫Secondary infections among HCW’s household contacts Especially important in pediatric centers: ▫Large reservoir of disease in pediatric hospitals ▫Large proportion of hospitalized children at high risk of severe influenza Growing interest in potential role of mandates ▫Recommended by the CDC and endorsed by IDSA, SHEA, AAP ▫Mandates successfully implemented at several other U.S. health systems

4. Nosocomial Influenza at CHOP (2000-2006)

5. Complications experienced by 56 patients with nosocomial influenza* Number (%) Death2 (3.6%) Respiratory failure3 (5.4%) Suspected bacterial pneumonia12 (21.4%) Bacteremia1 (1.8%) *2000-2004; complications determined by detailed chart review Coffin, ICHE, 2009.

6. Preventing nosocomial influenza: why is HCW vaccination critical? Virus primarily transmitted by large respiratory droplets ▫Less benefit from hand hygiene Virus can be shed 24 hrs before symptom onset Adults can have asymptomatic infections ▫20-50% of infected HCW were asymptomatic Many hospitalized pediatric patients too young to receive vaccine or unable to mount protective immune response

7. Vaccination reduces the rate of nosocomial influenza Observational study at University of Virginia hospital Over 13 seasons Increasing vaccination rate among HCW associated with reduced proportion of nosocomial influenza (32% in 1987-88 to 3% in 1998 - 99) Salgado, ICHE, 2004

8. Direct Benefits of HCW Vaccination Talbot, ICHE, 2005

9. Improving HCW Vaccination Rates: Strategies that work Education ▫Risks of disease 1,2 ▫Vaccine safety and efficacy 2 Internal marketing 1,3 Improving access to vaccine ▫Mobile carts 1,2 ▫Walk-in clinics, after-hours clinics 2 Expanding responsibility ▫Vaccine deputies 1 ▫Charge nurses as educators 2 1) Bryant, ICHE 2004; 2) Tapiainen ICHE 2005; 3) Spillman, 40 th National Immunization Conference Atlanta, March 2006

10. Cognitive Dissonance 101 Flu is bad for me and my patients. I don’t get flu vaccine. Employer: “Get Vaccinated!” I will get vaccinated. Flu vaccine is unsafe. Flu vaccine doesn’t work. You Can’t Make Me!!! ?????????? ?????????? I don’t get flu.

11. Wake Forest Declination Form (2005) “I realize I am eligible for the flu shot and that my refusal of it may put patients, visitors, and family with whom I have contact, at risk should I contract the flu. Regardless...” Adoption was associated with doubling of immunization rates (35% to 70% over 4 yr period) Spillman SS presented at 40 th National Immunization Conference Atlanta, March 2006

12. Are Declination Forms Enough? PRO HCW vaccination no longer a “passive decision” Provides final opportunity to frame issue Creates focus on individual accountability CON Signals acceptance of non- vaccination Polarizing effect reported by some

13. What level of HCW vaccination is ideal? Likely related to proportion of vaccinated staff and patients… ▫Retrospective study of 301 nursing homes (2004-2005) ▫Combined immunization rate of staff and residents inversely associated with risk of outbreak ▫60% reduced risk of outbreak associated with staff immunization rates of 55% and resident immunization rates of 89% (OR 0.41; 95% CI 0.19, 0.89) Shugarman, J Am Med Dir Assoc, 2006

15. 2004-20052005-20062006-20072007-20082008-20092009-2010 57%69%73%90%92%99.6% Targeted group(s) Direct care providers * in high risk settings # All direct care providers * All ^ who work in building where patient care is delivered Education and Communication Mandatory education module included in fall core curriculum Linked to pandemic flu preparedness Linked to patient safety Remedial education $ Town hall meetings LogisticsExpanded Occupational Health clinic hours Unit- and practice-based flu captains Flu vaccine clinics held at meetings Roving vaccination carts Declination FormNone Voluntary Mandatory AdministrativeSenior administration stresses importance of flu vaccination to clinical leaders Biweekly compliance reports @ Weekly compliance reports @ Use of LAIV ^ Offered to providers who did not work in high risk setting # Offered to all providers except those who worked on oncology unit

16. Why CHOP HCW decline flu vaccine 2005-20062006-2007 Allergy/Reaction3926 Rec’d vaccine elsewhere366 Concern about side effects34193 Never get flu927 Personal choice11953 Religious10 Other3215 Pregnancy115 Fear of needles70 TOTAL276392

17. Vaccination of physicians 16% MD groups >80% (5/31) 53% MD groups >80% (19/36) 22% MD groups fully vaccinated (8/36) 81% of MDs vaccinated (623/777) 2007-2008 2008-2009

18. 2009-2010 CHOP Employee Influenza Vaccine Program July, 2009: “The CHOP Patient Safety Committee recommends mandatory annual influenza vaccine for all staff* working in buildings where patient care was provided or whom provide patient care.” *includes clinicians, support staff, volunteers, students; vendors informed of policy and asked to ensure compliance.

19. Key Strategies, 2009-2010 PROGRAM ELEMENTS Create accurate list of targeted staff and assure ability to provide timely, accurate reports Establish method for evaluating requests for medical and religious exemptions Determine timeline and educate

20. Program Timeline, 2009-2010 PLAN: 6 week program (9/15-10/31/09) 2 week furlough for staff unvaccinated and without exemption as of 11/1/09 Termination if unvaccinated and without an exemption as of 11/15/09 REALITY: 2 week extension due to delays in receipt of seasonal flu vaccine

21. What happened: 2009-2010 >9000 HCW vaccinated 50 persons established medical exemptions 2 persons established religious exemptions 145 received temporary suspension 9 persons terminated

22. Labor Relations 101 2 meetings to negotiate ▫Impasse declared

23. Quotes from 10/26/09 negotiation: “You’re not making sure everyone who comes into CHOP is vaccinated.” “Why can’t we just wear masks all winter?” “No other institutions or regulatory groups support this.” “This discriminates against employees who have less access to educational resources on the internet.”

24. Labor Relations 102 Grievance filled (November, 2010) ▫CHOP: Termination for just cause  “Behaviors that are detrimental to the institution  “insubordination” ▫Union: Breech of contract  Not included in negotiated contract

25. Findings and Opinions from Arbitration: “There can be no doubt that the Hospital had the right to promulgate a ‘reasonable’ rule/condition of employment that would better ensure the health and safety of CHOP’s patient population.” “It is this Arbitrator’s finding that the policy implemented by the Hospital was reasonable in the context of the Hospital’s young, vulnerable patient community.”

26. Year 2 Experience: 2010-2011 >9500 HCW vaccinated Request for medical exemptions by 7 HCW (all granted) Request for religious exemptions by 3 HCW ▫Review by retired judge ▫2 granted, 1 denied No suspensions or terminations.

28. Evaluating Impact of Vaccine Mandate: METHODS: ▫Cross-sectional study of a random sample of HCW subjected to the mandate ▫Anonymous 20 item questionnaire adapted from validated previously published instrument (electronic>>paper distribution) 8,093 HCW’s 25% clinical (n=1450) 50% non- clinical (n=1100)

29. Study Question: What predicts agreement with the mandate? Primary outcome: attitude towards influenza vaccine mandate ▫“Do you agree with CHOP’s policy that requires all health care workers to receive annual flu vaccination (a flu shot or the nasal spray vaccine) unless there is a medical or religious contraindication”

30. Results: Survey Response rate (58%): ▫1,388 respondents (total distributed = 2,443)  657 (47%) clinical  731 (74%) nonclinical Respondent characteristics: ▫77% female ▫65% < 45 years of age ▫68% have worked at CHOP <10 years ▫90% staff previously vaccinated 91% felt they had received info they needed from CHOP to make decision about flu vaccination

31. Results: Reasons for vaccination Of those who had been vaccinated in past, majority of respondents cited: ▫Protection of self, family and patients ▫Job responsibility ▫Education received at work Of those who declined flu vaccination in past, majority of respondents cited: ▫Not being at high risk ▫Fear of side effects ▫Belief that vaccine is not effective

32. Results: Agreement with mandate 77% respondents intended to be vaccinated before hearing about the mandate 75% reported agreeing with mandate 23% of respondents strongly considered declining the flu vaccine after hearing about the mandate 72% reported agreeing that the mandate is coercive but almost everyone (96%) also agreed that mandatory policies are important for protecting patients

33. Results: Agreement with mandate ~75% of both clinicians and non-clinicians agree that societal rights outweigh individual rights when it comes to vaccination ~95% of both groups agree that parents have an obligation to make sure their children receive recommended vaccines >95% of both groups agree with policies for requiring vaccination or screening for TB, HepB, measles, rubella and varicella

34. Predictors of Agreement with Mandate Demographic PredictorsAttitudinal Predictors Contact with high risk individuals at home or at work Age Amount of time working at CHOP Gender Previous receipt of flu vaccine Previous experience with flu vaccine Reasons for previous flu vaccine receipt Reasons for previous flu vaccine declination Attitudes towards influenza prevention Intention to receive the vaccine before knowledge of the mandate Attitudes towards other mandatory vaccination programs Attitudes towards vaccines in general

35. Factors associated with Agreement with Mandate: unadjusted results Unadjusted OR (95% C.I.) Clinical (vs. Non-clinical) 1.49 (1.32, 1.68) Previous vaccination Yes (vs No) 6.3 (5.10, 7.79) Intention to be vaccinated before mandate, Yes (vs No) 10.6 (9.1, 12.5) Belief in Mandate benefits 29.0 (24.3, 34.6) Support other employment mandates 4.02 (3.36, 4.80) Ethical beliefs regarding vaccines / public health 6.87 (6.00, 7.86)

36. Factors associated with Agreement with Mandate: multivariable model Unadjusted OR (95% C.I.) Adjusted OR (95% C.I.) Clinical (vs. Non-clinical) 1.49 (1.32, 1.68) 1.08 (0.94, 1.26) Previous vaccination Yes (vs No) 6.3 (5.10, 7.79) 1.68 (1.29, 2.19) Intention to be vaccinated before mandate, Yes (vs No) 10.6 (9.1, 12.5) 2.64 (2.17, 3.21) Belief in Mandate benefits 29.0 (24.3, 34.6) 14.08 (11.5, 17.2) Support other employment mandates 4.02 (3.36, 4.80) 1.40 (1.13, 1.73) Ethical beliefs regarding vaccines / public health 6.87 (6.00, 7.86) 3.15 (2.70, 3.70)

37. Possible Implications Majority report that mandate is coercive ▫Does not appear to affect agreement with mandate Factors associated with agreement with mandate represent attitudes and beliefs that may be modifiable through targeted outreach and educational activities ▫May need to focus upon different key themes for clinical and non- clinical staff Reasons for previous declination of vaccination show that misconceptions regarding risk for infection and vaccine safety and efficacy do persist ▫Educational modalities may not be effectively communicating key messages

38. Do Mandates Improve Patient Outcomes?

39. Nosocomial influenza poses a serious threat to hospitalized children. HCW vaccination rates can be substantially improved through implementation of various voluntary measures. Mandates may be required to achieve maximal levels of HCW compliance but many HCW may support mandates and believe that they are important way to protect patients and staff Attitudes and beliefs associated with support of mandate may transcend professional role Summary

40. Questions?

41. Acknowledgements: Occupational Health - Mary Cooney Infection Prevention and Control - Keith St. John - Eileen Sherman Infectious Diseases Epidemiology Research Group - Kristen Feemster - Priya Prasad All CHOP Healthcare Workers