1. 1 Local Jurisdiction’s Health Officer Order Mandating Influenza Vaccination of Healthcare Personnel in Los Angeles County: Preliminary Findings Jessica Silvaggio, MPH CDC/ CSTE Applied Epidemiology Fellow Acute Communicable Disease Control Los Angeles County Department of Public Health

2. 2 Morbidity and Mortality Influenza: 6 th leading cause of death among US adults –Accounts for 23,000 deaths 200,000+ annual hospitalizations for respiratory and heart conditions illnesses associated with seasonal influenza virus infections

3. Recent data supporting HCP vaccination Presented at 41 st annual conference of APIC this summer An analysis of 2009-2012 CDPH data Purpose: To determine relationship between vaccinating HCP against influenza and rate of influenza-like illness in surrounding community

4. Study Conclusion Conclusion: –For every 15 healthcare providers who receive the influenza vaccination, 1 fewer persons in the community will contract an influenza-like illness –For the 2011-2012 influenza season, the influenza vaccination rate of California hospital HCP was 68% If 90% of California’s healthcare personnel were vaccinated---Healthy People 2020 initiative goal-- there would be approximately 30,000 fewer cases of influenza-like illness in California 4

5. Hospital-Onset Influenza Data used from hospitals were part of Influenza Hospitalization Surveillance Network (FluSurv- NET) –Network conducting population-based surveillance in 16 states 6,171 influenza-positive hospitalizations –172 (2.8%) were defined as hospital-onset (>3 days after admit) Source M.A. Jhung et al. AJIC 42(2014)7-11

6. Study Conclusion Hospital-onset cases had greater length of stay and were more likely to be admitted to the intensive care unit or die compared with community-onset cases Source M.A. Jhung et al. AJIC 42(2014)7-11 6

7. 7 Supporting Rationale Unvaccinated HCP can transmit flu to other HCP and patients –Up to 25% of HCP infected with flu each season HCP more likely to work when ill than other professions Asymptomatic HCP can spread influenza unknowingly

8. 8 Benefits of Immunized Workforce Reduced absenteeism Increased productivity Effective in reducing influenza among HCP and patients Decreased morbidity and mortality among patients

9. Study Objectives To evaluate the impact of the 2013 DPH Order on: 1.HCP vaccination rates 2.Patient safety –Incidence of nosocomial influenza 3.Worker absenteeism

10. Study Basics Included in the study are the 94 acute care facilities in LAC (excluding Pasadena and Long Beach) –2 seasons pre-order, 1 season post-order The study involves: –Review of mandatory reported HCP vaccination data –Direct laboratory influenza testing results –Survey data from IPs –Data from HR directors / staff on employee sick leave

11. HCP Vaccination Rates Using California DPH mandatory HCP vaccination reporting data Look for impact of order –Expect increase in rates overall –Expect greatest increase in those facilities who did NOT previously practice mandatory masking (or other consequences) for those who declined vaccine

12. Patient Safety: Nosocomial Influenza Data from: 1.IP survey 2.Lab reporting New positive flu test obtained > 72 hours from admit

13. HCP Absenteeism Data from Human Resources / Admin –Number of sick days per total employees Challenge –Who to contact for this information? –We have enlisted your help –You all received an email asking that you please: 1.Identify correct person in HR or other admin office (payroll, etc.) who can report # of sick days for hospital employees 2.Forward the email to that correct person

14. Survey Snapshot Web-based (Qualtrics) Includes: –nosocomial flu surveillance, definitions, and lab diagnostic method(s) –data on nosocomial influenza cases from 2013-2014 2012-2013 2011-2012 –Details on each case Sex, age, symptoms, patient location, etc. –HCP vaccination policies at your facility –Implementation of the DPH 2013 order

15. More about the survey Includes: –HCP vaccination rates –HCP vaccination policies at your facility –Implementation of the DPH 2013 order Tracking and enforcing Level of difficulty and overall acceptance of order

16. IP Line Lists Asked to provide line list of cases identified as nosocomial / hospital-onset influenza Provides details and characterization of cases 16

17. Preliminary Results 29 IP surveys completed 14 IP line lists completed of cases identified as nosocomial / hospital-onset influenza 13 Lab Director line lists completed of positive flu test obtained > 72 hours from admit 16 Absenteeism forms completed 8 Facilities have completed all study components 17

18. Descriptive Statistics Among facilities with a completed IP survey –8 (of 29) are teaching facilities 18

19. 19 VariableN% No. of Reported Nosocomial Flu Cases 55 Age (mean)65.04 Gender (female)2545.4 Hospitalization location General Ward3869.1 Intensive Care Unit59.1 Respiratory Unit35.4 Definitive Observation Unit35.4 Pediatric Unit23.6 Rehabilitation Unit11.8 Critical Care Unit23.6 Post partum11.8 Nosocomial Cases in 2011-1211.8 Nosocomial Cases in 2012-133360.0 Nosocomial Cases in 2013-142138.2 IP Line List Descriptive Statistics

20. Employee Absenteeism Includes facility employees and staff, without distinguishing HCP 20 Influenza SeasonAverage missed days per employee* 2011-20123.9 2012-20135.2 2013-20141.0 *Includes facilities with complete numerator and denominator data †(n=14)

21. Healthcare Personnel Vaccination/ Masking Rates Influenza Season% of employees vaccinated % of employees who declined vaccination % of employees with an unknown vaccination status 2011-201269.425.65.6 2012-201375.924.83.6 2013-201487.29.52.7 †(n=29) 21

22. Implementation of the Health Officer Order On a scale of 0-5: –22 participants reported an average value of 2.77 (moderate difficulty relative to overall ease of implementation) –23 participants reported an average value of 3.09 (fairly well accepted relative to overall HCP acceptance of the Health Officer Order) –2.94 (among nurse practitioners) and 2.90 (among other employees with patient contact) moderate resistance relative to the amount of resistance encountered from HCP 22

23. Highlights Variability in surveillance definitions across facilities –>48 hours –72 + hours –No timing reported Approximately half of respondents (45%) indicated obtaining additional vaccine for HCP following the order; Vaccine successfully obtained by all respondents 23

24. Limitations Absenteeism reported differently across facilities –May include vacation time –May include employees without direct patient contact Limited responses and incomplete data hinder robust analysis Inherent variability between flu seasons creates challenges in analysis 24

25. Timeline This month –Receive follow up emails and phone calls to obtain project components –IPs are asked to please identify and forward to correct HR person to assist with sick leave data Send contact information to Jessica Silvaggio (jsilvaggio@ph.lacounty.gov) Fall 2014 –Present findings at local APIC chapters, conference calls, highlights, and conferences

26. Thank you!

27. Acknowledgements Allison Bearden Dawn Terashita Patricia Marquez Sharon Sakamoto ACDC HOU Nurses Los Angeles County Infection Preventionists Los Angeles County Lab Directors Los Angeles County HR/ EH Personnel 27

28. Questions 28 Study Contacts: Allison Bearden, MD/ MPH Study Coordinator 626-457-5820 Email: abearden@dhs.lacounty.govabearden@dhs.lacounty.gov Jessica Silvaggio, MPH Study Co-coordinator 213-240-7941 Email: jsilvaggio@ph.lacounty.govjsilvaggio@ph.lacounty.gov Dawn Terashita, MD/ MPH Medical Epidemiologist 213-240-7941 Email: dterashita@ph.lacounty.govdterashita@ph.lacounty.gov Patricia Marquez, MPH Epidemiologist 213-240-7941 Email: pmarquez@ph.lacounty.govpmarquez@ph.lacounty.gov