Pennsylvania Health Care Worker Flu Immunization Campaign

1. Pennsylvania Health Care Worker Flu Immunization CampaignA Patient Safety & Employee Health InitiativeTraining Resources:Policy ModuleVersion 1.4June 2011

2. Pennsylvania Health Care Worker Flu Immunization Campaign • Using Healthy People 2020 benchmark as anchor for program • This presentation reviews current public health policy recommendations around mandatory HCW seasonal influenza vaccination… • Brief look at PA Patient Safety Authority data on impact of mandatory programs in PA NHs • Case Study Module addresses Best Practices, and recognizes “promising practices” as important interim strategies

3. Healthy People 2020 • Vision • A society in which all people live long, healthy lives. • Mission • Healthy People 2020 strives to: • - Identify nationwide health improvement priorities. • Increase public awareness and understanding of the determinants of health, disease, • and disability and the opportunities for progress. • Provide measurable objectives and goals that are applicable at the national, state, and • local levels. • Engage multiple sectors to take actions to strengthen policies and improve practices • that are driven by the best available evidence and knowledge. • - Identify critical research, evaluation, and data collection needs. • Overarching Goals • Attain high-quality, longer lives free of preventable disease, disability, injury, and • premature death. • - Achieve health equity, eliminate disparities, and improve the health of all groups. • - Create social and physical environments that promote good health for all. • Promote quality of life, healthy development, and healthy behaviors across all life • stages.

5. Public Health Policy and HCW Flu Vaccination • Number and strength of evidence-based recommendations for mandatory HCW seasonal flu vaccination are building • Common theme: mandatory HCW seasonal flu vaccination is the ethical, effective and indicated program model • Specific language from key recommendations from:

6. 2010 National Vaccine Plan The National Vaccine Plan is the nation’s roadmap for a 21st century vaccine and immunization enterprise and the 10-year strategy to ensure that all Americans can access the preventive benefits of vaccines. It includes strategies for advancing vaccine research and development, financing, supply, distribution, safety, global cooperation, and informed decision-making among consumers and health care providers.  [National Vaccine Program Office/HHS] http://www.hhs.gov/nvpo/vacc_plan/index.html See Beauchamp, TL, Childress, JF Principles of Biomedical Ethics

7. 2010 National Vaccine Plan: Health Care Providers Objective • Objective 4.6 • Educate and support health care providers in vaccination counseling and vaccine delivery for their patients and themselves. • Strategies • 4.6.8 • Develop, implement, and evaluate comprehensive programs to ensure health care professionals are appropriately immunized with recommended vaccines. http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/4/809 See Beauchamp, TL, Childress, JF Principles of Biomedical Ethics

8. Recommendation for Mandatory Influenza Immunization of All Health Care PersonnelHenry H. Bernstein, DO, Jeffrey R. Starke, MD and Committee on Infectious DiseasesOctober 2010 Abstract The purpose of this statement is to recommend implementation of a mandatory influenza immunization policy for all health care personnel. Immunization of health care personnel is a critically important step to substantially reduce health care–associated influenza infections. Despite the efforts of many organizations to improve influenza immunization rates with the use of voluntary campaigns, influenza coverage among health care personnel remains unacceptably low. Mandatory influenza immunization for all health care personnel is ethically justified, necessary, and long overdue to ensure patient safety. PEDIATRICS Vol. 126 No. 4 October 2010, pp. 809-815 (doi:10.1542/peds.2010-2376) http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/4/809 See Beauchamp, TL, Childress, JF Principles of Biomedical Ethics

9. Recommendation for Mandatory Influenza Immunization of All Health Care PersonnelHenry H. Bernstein, DO, Jeffrey R. Starke, MD and Committee on Infectious DiseasesOctober 2010 “… Mandatory programs for all HCP should be implemented nationwide… Medical and religious exemptions to required influenza immunization can be granted on an individual basis. Individual organizations and practices must decide at a local level (how to address) the additional objections to vaccination, (those) which may be required by state law (eg, philosophical), (those) that are reasonable and the ones they are willing to accept for an individual to be granted an exception and be allowed to continue to work. Policies should be developed for management of exempted HCP during influenza season, including efforts to ensure patient and staff safety and to identify ill HCP. “ PEDIATRICS Vol. 126 No. 4 October 2010, pp. 809-815 (doi:10.1542/peds.2010-2376) http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/4/809 See Beauchamp, TL, Childress, JF Principles of Biomedical Ethics

10. ACP Policy on Influenza Vaccination of Health Care Workers “The recommendation of the Adult Immunization Advisory Board is that a series of educational activities be centered on this message: An annual influenza vaccine should be required for every health care worker with direct patient care activities, unless a medical contraindication to influenza immunization exists or a religious objection to immunization exists. If, however, health care workers invoke those exceptions, they must still fulfill their ethical obligations to patients and colleagues by not engaging in direct patient care activities if flu-like symptoms are present. In addition, those health care workers who cannot receive flu vaccines due to medical or religious contraindications should either be re-assigned to non-patient care areas during influenza season or wear a mask at all times during influenza season in the context of patient care.”

11. Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel Author: SHEADate Published: 9/2/2010 10:16:00 AMAbstract: In large part, the discussion about the rationale for influenza vaccination of healthcare personnel, the strategies designed to improve influenza vaccination rates in this population, and the recommendations made in the 2005 paper still stand. This position paper notes new evidence released since publication of the 2005 paper and strengthens SHEA’s position on the importance of influenza vaccination of HCP. This document does not discuss vaccine allocation during times of vaccine shortage, because the 2005 SHEA Position Paper still serves as the society’s official statement on that issue. SHEA views influenza vaccination of HCP as a core patient and HCP safety practice with which noncompliance should not be tolerated. Therefore, for the safety of both patients and HCP, SHEA endorses a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges. http://www.shea-online.org/View/smid/428/ArticleID/5.aspx

12. National Patient Safety Foundation Supports Mandatory Flu Vaccinations for Healthcare Workers The National Patient Safety Foundation recognizes vaccine-preventable diseases as a matter of patient safety and supports mandatory influenza vaccination of health care workers to protect the health of patients, health care workers, and the community. NPSF appreciates that where vaccination is not possible for any reason, due to unavailability or medical contraindications of potential vaccine recipients, hospitals and healthcare professionals must use all available alternatives to avoid transmission to patients and coworkers including masks and adjusting job responsibilities. http://www.npsf.org/pr/pressrel/2009-11-18.php

13. 2010-11 Influenza Prevention & Control Recommendations – Additional Information about Vaccination of Specific Populations • All HCP and persons in training for health-care professions should be vaccinated annually against influenza. Persons working in health-care settings who should be vaccinated include physicians, nurses, and other workers in both hospital and outpatient-care settings, medical emergency–response workers (e.g., paramedics and emergency medical technicians), employees of nursing home and long-term–care facilities who have contact with patients or residents, and students in these professions who will have contact with patients… http://www.cdc.gov/flu/professionals/acip/specificpopulations.htm

14. 2010-11 Influenza Prevention & Control Recommendations – Additional Information about Vaccination of Specific Populations • Facilities that employ HCP should provide vaccine to workers by using approaches that have been demonstrated to be effective in increasing vaccination coverage. The HCP influenza coverage goal should be vaccination of 100% of employees who do not have medical contraindications. Health-care administrators should consider the level of vaccination coverage among HCP to be one measure of a patient safety quality program and consider obtaining signed declinations from personnel who decline influenza vaccination for reasons other than medical contraindications. Influenza vaccination rates among HCP within facilities should be measured regularly and reported, and ward-, unit-, and specialty-specific coverage rates should be provided to staff and administration… http://www.cdc.gov/flu/professionals/acip/specificpopulations.htm

15. 2010-11 Influenza Prevention & Control Recommendations – Additional Information about Vaccination of Specific Populations • Policies that work best to achieve this coverage goal might vary among facilities. Studies have demonstrated that organized campaigns can attain higher rates of vaccination among HCP with moderate effort and by using strategies that increase vaccine acceptance. A mandatory influenza vaccination policy for HCP, exempting only those with a medical contraindication, has been demonstrated to be a highly effective approach to achieving high vaccine coverage among HCP. Hospitals and health-care systems that have mandated vaccination of HCP often have achieved coverage rates of more than 90%, and persons refusing vaccination who do not have a medical contraindication have been required to wear a surgical mask during influenza season in some programs… http://www.cdc.gov/flu/professionals/acip/specificpopulations.htm

16. IDSA Policy on Mandatory Immunization of Health Care Workers Against Seasonal and Pandemic Influenza The Infectious Diseases Society of America (IDSA) supportsuniversal immunization of health care workers (HCWs) against influenza by health care institutions (inpatient and outpatient) through mandatory vaccination programs, as these programs are the most effective means to protect patients against the transmission of seasonal and pandemic influenza by HCWs. IDSA supports a policy in which influenza vaccination is a condition of employment, unpaid service, or receipt of professional privileges. Employees who cannot be vaccinated due to medical contraindications or because of vaccine supply shortages should be required to wear masks or be re-assigned away from direct patient care… www.idsociety.org/redirector.aspx?id=15413

17. IDSA Policy on Mandatory Immunization of Health Care Workers Against Seasonal and Pandemic Influenza …IDSA also is supportive of comprehensive educational efforts that inform HCWs about the benefits and risks of influenza immunization to both patients and HCWs, and other efforts that support implementation of a comprehensive infection control program. • Original policy contained in IDSA’s Pandemic and Seasonal Influenza Principles for U.S. Action (See: Recommendation 6); January 2007 • Revised to address 2009 H1N1 influenza; remove declination for philosophical reasons; and to specify the steps that should be taken to protect patients from being infected by unimmunized HCWs; September 30, 2009 • Revised to specify that annual influenza vaccination should be a condition of initial and continued employment and/or professional privilege; and to remove declination for religious reasons; July 28, 2010 www.idsociety.org/redirector.aspx?id=15413

18. IDSA Policy on Mandatory Immunization of Health Care Workers Against Seasonal and Pandemic Influenza RATIONALE: 1) Several studies demonstrate that immunizing HCWs against influenza protects patients against acquiring the virus from HCWs, reducing patient morbidity and mortality—thus, universal immunization of HCWs against seasonal and pandemic influenza is a critical patient safety issue. 2) Immunizing HCWs against seasonal and pandemic influenza also protects the individual HCW from falling ill due to these potentially life-threatening infections as well as from missing work during influenza outbreaks, further negatively impacting patient care. 3) Decades of scientific data demonstrate Food and Drug Administration-approved influenza vaccines to be safe, effective, and cost-saving. 4) Educational programs and easy access to influenza immunization have resulted in mildly improved coverage in many health care systems in recent years, but generally have not achieved acceptable levels of coverage—most successful educational programs still average only 40 to 70 percent coverage. 5) Several large health care systems and individual hospitals have adopted policies requiring mandatory influenza immunization such that employees who cannot be vaccinated or who choose not to be vaccinated are required to wear masks or are re-assigned away from direct patient care. 6) Physicians and other health care providers must have two special objectives in view when treating patients, namely, “to do good or to do no harm" (Hippocratic Corpus in Epidemics: Bk. I, Sect. 5, trans. Adams), and have an ethical and moral obligation to prevent transmission of infectious diseases to their patients. www.idsociety.org/redirector.aspx?id=15413

19. The Pennsylvania Patient Safety Authority. PA-PSRS 2010 annual survey. 2010. [unpublished results].

20. The Pennsylvania Patient Safety Authority. PA-PSRS 2010 annual survey. 2010. [unpublished results].

21. The Pennsylvania Patient Safety Authority. PA-PSRS 2010 annual survey. 2010. [unpublished results].

22. Group Exercise • Share language from your institution’s patient bill-of-rights or similar standard that specifically addresses patient safety. How does it relate to the recommendations discussed? • Share language from your institution’s current HCW flu vaccination policy. How does it align to the recommendations discussed? We will use these examples to build a collection of “policy issues and (potential) answers” for the website

23. Opening paragraphs of policy: see http://pahcwfluvax.org/case-studies/main-line-health-case-study/

24. VaccineVolume 28, Issue 13, 16 March 2010, Pages 2517-2521 Physician attitudes towards influenza immunization and vaccine mandatesJennifer E. deSante, Arthur Caplan, Frances Shofer, Amy J. Behrman Abstract Aim: We surveyed physicians’ opinions and acceptance of influenza immunization. Scope: A web-based survey was sent to all physicians in two academic departments during spring 2009. Results: 227 (40.5%) physicians responded. Physicians who frequently cared for high-risk patients self-reported higher immunization rates than physicians with infrequent contact (P = 0.0002). There were no significant differences in immunization rates between emergency medicine (EM) and internal medicine (IM), between those with and without children at home, nor by age group. A majority (84.6%) supported mandatory vaccination. IM physicians were more supportive of mandates than EM physicians (P < 0.0001). Conclusion: Self-reported immunization rates were high among study physicians. Acceptance of mandatory vaccination was substantial, but varied by specialty.

25. Vaccine Volume 29, Issue 9 pp. 1727-1854 (17 February 2011) Regular Papers Employee designation and health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital Original Research Article  [pdf here:  Vaccine_Feemster et al_HCW Flu Vaccinations_Feb 2011 ]Kristen A. Feemster, Priya Prasad, Michael J. Smith, Chris Feudtner, Arthur Caplan, Paul Offit, Susan E. CoffinAbstractAim: Determine predictors of support of a mandatory seasonal influenza vaccine program among health care workers (HCWs).Scope: Cross-sectional anonymous survey of 2443 (out of 8093) randomly selected clinical and non-clinical HCWs at a large pediatric network after implementation of a mandatory vaccination program in 2009–10.Results388 HCWs (58.2%) completed the survey and 75.2% of respondents reported agreeing with the new mandatory policy. Most respondents (72%) believed that the policy was coercive but >90% agreed that the policy was important for protecting patients and staff and was part of professional ethical responsibility. When we adjusted for attitudes and beliefs regarding influenza and the mandate, there was no significant difference between clinical and nonclinical staff in their support of the mandate (OR 1.08, 95% C.I. 0.94, 1.26).ConclusionsAttitudes and beliefs regarding influenza and the mandate may transcend professional role. Targeted outreach activities can capitalize on beliefs regarding patient protection and ethical responsibility.

26. Appendix: Joint Commission Standards 2011 Q&A on HCW seasonal influenza vaccination Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of Pennsylvania NVAC Health Care Personnel Influenza Vaccination Subgroup 31 May 2011

27. Joint Commission on Accreditation of Health-Care Organizations 3/3/2011 Q: What does my organization have to do about this year’s influenza season to satisfy Joint Commission requirements? A: Critical Access Hospitals, Hospitals, and Long Term Care facilities have a standard specific to Healthcare Worker Influenza Vaccination Programs (See standard IC.02.04.01).  Other health care settings, such as Ambulatory Care, Home Health Care, Laboratory, and Behavioral Health Care (for example, day care and residential) settings do not have specific standards; however, as part of their infection prevention and control activities these organizations need to assess their risks and take actions to protect their patients and health care workers (See standards IC.01.03.01 and IC.02.01.01)… Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of Pennsylvania NVAC Health Care Personnel Influenza Vaccination Subgroup 31 May 2011 http://www.jointcommission.org/about/JointCommissionFaqs.aspx?faq#433

28. Joint Commission on Accreditation of Health-Care Organizations 3/3/2011 … In 2006, The Joint Commission announced a new infection control standard requiring accredited hospitals, critical access hospitals, and long term care facilities to offer influenza vaccinations to health care workers, including licensed independent practitioners and volunteers. The Joint Commission developed the standard in response to recommendations by the Centers for Disease Control and Prevention (CDC) making the reduction of influenza transmission from health care professionals to patients a top priority in the United States… Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of Pennsylvania NVAC Health Care Personnel Influenza Vaccination Subgroup 31 May 2011

29. Joint Commission on Accreditation of Health-Care Organizations 3/3/2011 …The Joint Commission standard IC.02.04.01 requires Critical Access Hospitals, Hospitals, and Long Term Care facilities to do the following: • Establish an annual influenza vaccination program that includes, at a minimum, staff and licensed independent practitioners. • Provide access to influenza vaccinations on site. • Educate staff and licensed independent practitioners about influenza vaccination, non-vaccine control measures (such as hand hygiene, sneeze and cough etiquette), and the diagnosis, transmission, and potential impact of influenza. • Annually monitor vaccination rates and reasons for nonparticipation in the organization’s immunization program. • Implement enhancements to the program to increase participation. Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of Pennsylvania NVAC Health Care Personnel Influenza Vaccination Subgroup 31 May 2011

30. Joint Commission on Accreditation of Health-Care Organizations 3/3/2011 Q: Does The Joint Commission require signed influenza vaccination declination forms? A: No. The Joint Commission does not require declinations from individuals refusing influenza vaccination. For Critical Access Hospitals, Hospitals, and Long Term Care facilities, the Joint Commission does require that organizations collect and evaluate reasons health care workers do not get vaccinated in order to improve the organization’s health care worker influenza program. It does benefit ALL health care settings to understand why their health care workers do not get vaccinated in order to protect their patients, residents, or individuals served… Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of Pennsylvania NVAC Health Care Personnel Influenza Vaccination Subgroup 31 May 2011

31. Joint Commission on Accreditation of Health-Care Organizations 3/3/2011 …However, the CDC’s Interim Guidance on Infection Control Measures for 2009 H1N1 Influenza in Healthcare Settings, Including Protection of Healthcare Personnel posted on October 14, 2009, states To improve adherence, vaccination should be offered to healthcare personnel free of charge and during working hours. Vaccination campaigns with incentives such as lotteries with prizes should be considered. Healthcare facilities should require personnel who refuse vaccination to complete a declination form.” (Accessed 10/16/09) The Occupational Safety and Health Administration (OSHA) will also be releasing further guidance within the next several weeks. View the OSHA statement from October 14, 2009. (Accessed 10/16/09). Adapted from: Jason L. Schwartz, MBE, AM, Center for Bioethics; Department of History & Sociology of Science University of Pennsylvania NVAC Health Care Personnel Influenza Vaccination Subgroup 31 May 2011