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Influenza Vaccination: Providing Standard of Care

Influenza Vaccination: Providing Standard of Care. Presentation to: Georgia Hospital Association Presented by: Matthew B. Crist , MD, MPH Date: September 27, 2012. Outline. Who should be vaccinated and vaccines offered Contraindications and side effects

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Influenza Vaccination: Providing Standard of Care

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  1. Influenza Vaccination: Providing Standard of Care Presentation to: Georgia Hospital Association Presented by: Matthew B. Crist, MD, MPH Date: September 27, 2012

  2. Outline • Who should be vaccinated and vaccines offered • Contraindications and side effects • Strain selection and manufacturing of vaccine • Healthcare Worker Vaccination • Working Sick • Mortality Benefit • Improving vaccination rates • Mandates

  3. Who gets the flu? • From 5 -- 20 % of the U.S. population develops influenza each year. • This leads to more than 200,000 hospitalizations from related complications. • Persons at higher risk for complicated flu are: • People with asthma • People with diabetes • People with heart disease or history of stroke • People >65 years of age • Pregnant women • People with HIV infection • People with cancer • Children <5, especially those <2 years of age

  4. Who should get the shot? • Annual vaccination is recommended for all persons aged 6 months and older.

  5. 2012-2013 Algorithm for Children 6 mos. - 8 yrs.

  6. Types of Vaccines

  7. Contraindications • Under 6 months of age • History of anaphylactic reaction to vaccine or eggs • Moderate-to-severe illness with a fever (wait until they recover) • Guillain-Barre syndrome within six weeks of a previous influenza shot in a person not at high risk for complications from influenza • If the risk from influenza is high, they should be vaccinated because the established benefits of the vaccine justify vaccination

  8. Contraindications to LAIV • History of asthma or other reactive airway diseases • Chronic medical conditions that predispose to severe influenza infections • Pregnancy • History of Guillain-Barre syndrome • Acute serious illness with fever • LAIV should not be given concurrently with other live-virus vaccines

  9. Adverse Reactions • TIV • Soreness, redness, or swelling at the injection site • Fainting • Low grade fever • Muscle aches • Nausea • LAIV • Runny nose • Headache • Sore throat • Cough Can occur shortly after vaccine is given and usually last 1-2 days

  10. Adverse Reactions: Severe • Anaphylactic Reaction- Occur in less than 1 in 10,000 • Guillain-Barre Syndrome- Occur in approximately 1 in a million • Febrile Seizures- Increase associated with vaccine in Australian vaccine which is not used in the US • Safety is Monitored through • Vaccine Safety Datalink Project (VSD) • Vaccine Adverse Event Report System (VAERS)

  11. What’s on the horizon? • Quadrivalentlive attenuated influenza vaccine, FluMist Quadrivalent® (MedImmune) was approved February 2012 • Live, attenuated influenza vaccine • Administered as a nasal spray • Approved for use in people ages 2 through 49 years • The first to contain four strains of the influenza virus -- two influenza A and two influenza B lineage strains. • Anticipated to be available for 2013-2014 US season • Vaccines fromcell-basedmedia • UniversalVaccine?-target the stem of the hemagglutinin surface protein

  12. Vaccine Strain Selection Process • 130 national influenza centers in 101 countries conduct year-round surveillance for influenza and send influenza viruses to the 5 WHO Influenza collaborating centers : • Atlanta, GA (CDC) • London, UK(National Institute for Medical Research) • Melbourne, Australia (Victoria Infectious Diseases Reference Laboratory) • Tokyo, Japan (National Institute for Infectious Diseases) • Beijing, China (National Institute for Viral Disease Control and Prevention) • Experts from the FDA, the WHO, the CDC, and other public health experts identify virus strains likely to cause the most illness during the upcoming flu season.

  13. Vaccine Strains for 2012-2013 • The strains selected for inclusion in the 2012-2013 flu vaccines are: • A/California/7/2009 (H1N1)-like virus • A/Victoria/361/2011 (H3N2)-like virus • B/Wisconsin/1/2010-like virus.

  14. Influenza Vaccination in Healthcare Workers

  15. Prevention of Healthcare-Associated Influenza • Early identification/isolation of suspect cases • Source control/mask patient • Restrict ill visitors/healthcare personnel • Hand hygiene • Vaccination of patients • PPE • Antiviral prophylaxis • Vaccination of HCP

  16. Why is Healthcare Personnel Influenza Vaccination Important? • Frequent contact with high-risk patients • Serve as a vehicle for spread of flu • HCP absenteeism can stress health system • Influenza vaccination of HCP may reduce patient mortality • Model for their patients Talbot TR et al ICHE 2005;26:882+

  17. Healthcare-Associated Influenza • Outbreaks reported in most care areas • Influenza infection causes minimal or no symptoms in up to 25% • Such workers still shed (and spread) virus • 76.6% HCP work while ill with ILI • Worked mean 2.5 days while ill with ILI Talbot TR ICHE 2005;26:882 Stott DJ Occ Med 2002;52:249 Foy HM Am J Epi 1987;126:506 Weingarten S AJIC 1989;17:202 Lester RT ICHE 2003;24:839

  18. Risk of HA-ILI in Acute Care Setting • Prospective surveillance of pts and HCWs • App 20-25% ILI = influenza Vanhems P et al Arch Intern Med 2011;171:151+

  19. Healthcare personnel influenza vaccination coverage, US mid-November 2011 † "Other" includes allied health professionals, technicians/assistants and aides, and administrative and non-clinical support staff.

  20. Healthcare worker influenza vaccination coverage by age, US mid-November 2011

  21. Healthcare personnel influenza vaccination by work setting, US mid-November 2011

  22. Reason for healthcare worker reporting they will not be vaccinated during the flu season, US mid-November 2011

  23. Reported Reasons for Low HCP Vaccination Rates Heimberger T ICHE 1995;16:412 Lester RT ICHE 2003;24:839 Martinello RA ICHE 2003;24:845 Nichol KL ICHE 1997;18:189 Steiner M ICHE 2002;23:625 Weingarten S AJIC 1989;17:202

  24. HCP Vaccination & the Impact Upon Patient Mortality ns Patient Mortality (%) 20 LTCF/ arm N = 3483 pts 10 LTCF/ arm N = 1437 pts 22 LTCF/ arm N = 2604 pts 6 LTCF/ arm N = 1059 pts

  25. Lower patient mortality significantly correlated with HCP vaccination coverage Lemaitre M et al JAGS 2009

  26. Lower nosocomial influenza frequency significantly correlated with higher HCP vaccination coverage Salgado CD et al ICHE 2004;25:923+

  27. Methods to Improve HCP Vaccination Rates Make it a priority: • Strong and visible administrative leadership • Visible vaccination of key leaders • Vaccination champions • Provision of adequate staff and resources  • Train-the-trainer programs that empower unit staff Make it available: • Off-hours clinics • Use of mobile vaccination carts • Vaccination at staff/departmental meetings • Provision of vaccine free of charge Talbot TR ICHE 2005;26:882

  28. Methods to Improve HCP Vaccination Rates Tackle the myths: • Targeted education • Assess comprehension of the message Monitor and feedback progress: • Tracking of individual & unit-based HCP vaccination compliance • Surveillance for healthcare-associatedinfluenza Make it mandatory/hard to refuse • Signed declination statements • Condition of employment Talbot TR ICHE 2005;26:882

  29. Talbot TR Clin Infect Dis 2009;49:773+

  30. DECLINATION OF VACCINE - You MUST complete if refusing vaccine I am eligible to receive the influenza vaccine BUT do not want to take it. I understand that by refusing the vaccine I may be putting my FAMILY, FRIENDS and PATIENTS at risk of getting influenza. I am aware that hospitalized patients are at increased risk of getting serious complications following influenza infection. Please CHECK YOUR REASON(S) for not receiving the influenza vaccine.  Afraid of needles Afraid of side effects  Fear of getting influenza from the vaccine  Don’t believe in vaccines  Don’t think vaccines work  I never get the flu  Other: _____________________________________________________________________________

  31. Mandates and Healthcare Workers

  32. Conditions for Employment in Healthcare • Conditions for employment in place at many facilities • MMR or evidence of immunity • Hepatitis B vaccine series, evidence of immunity, or signed declination • Annual tuberculin skin testing • Varicella vaccine if no evidence of immunity

  33. 2005 Virginia Mason Medical Center Sources: www.immunize.org, University HealthSystem Consortium, Emerging Infections Network

  34. Virginia Mason Medical CenterMandatory Influenza Vaccination Program Rakita RM et al Infect Control Hosp Epidemiol 2010;31:881+

  35. 2007 Virginia Mason Medical Center Sources: www.immunize.org, University HealthSystem Consortium, Emerging Infections Network

  36. 2008 Virginia Mason Medical Center BJC Healthcare (11 hospitals) Sources: www.immunize.org, University HealthSystem Consortium, Emerging Infections Network

  37. Babcock HM et al CID 2010;50:459+

  38. Talbot TR Clin Infect Dis 2009

  39. 2009 Virginia Mason Medical Center U of Iowa CHOP/ Hospital of UPenn MedStar Health (9 hospitals) BJC Healthcare (11 hospitals) NC Baptist Hospital (Wake Forest) Emory Health Systems Sources: www.immunize.org, University HealthSystem Consortium, Emerging Infections Network

  40. 2009/10 Virginia Mason Medical Center U of Iowa CHOP/ Hospital of UPenn MedStar Health (9 hospitals) BJC Healthcare (11 hospitals) NC Baptist Hospital (Wake Forest) Emory Health Systems 163 Hospitals, 20 states Sources: www.immunize.org, University HealthSystem Consortium, Emerging Infections Network

  41. 2011-12 Virginia Mason Medical Center U. Wash. Medicine B-I Deaconess/ Children’s Hospital Boston U of Iowa CHOP/ Hospital of UPenn MedStar Health (9 hospitals) Johns Hopkins System BJC Healthcare (11 hospitals) NC Baptist Hospital (Wake Forest) Emory Health Systems 163 Hospitals, 20 states Sources: www.immunize.org, University HealthSystem Consortium, Emerging Infections Network

  42. Commonalities Among Those Institutions/Healthcare Systems That Have Mandated Influenza Vaccination of HCP • Dissatisfaction w/ rates already above national average • Strong leadership advocacy • Willing to take brunt of opposition • Patient and HCP safety emphasized • Initial implementation = intense • Resources • Challenges (HCP, unions) • Engrains into culture  “No big deal” (eventually) • Rates ≥ 95%

  43. Professional Societies and Organizations Endorsing Mandatory Influenza Vaccination of Healthcare Personnel Updated 2/13/2012

  44. Communication of Policy Daugherty et al. ICHE 2011

  45. Communication In summary, our findings suggest a need for more investigation of factors influencing HCW beliefs about vaccine effectiveness in order to tailor policies and programs to address not just adherence but the drivers behind it. Although we agree that mandatory vaccination will likely significantly improve adherence, the perception of unfairness and excessive pressure on the part of the institution is not a trivial concern. Policies that foster trust, rather than mistrust and resentment, are likely to be far more effective in the long run. Daugherty et al. ICHE 2011

  46. Acknowledgements • Tom Talbot, MD, MPH: Vanderbilt School of Medicine • Christine Hahn, MD: Idaho Dept. of Health and Welfare • Delmar Little, MPH: Georgia Dept. of Public Health • Jeanne Negley, MBA: Georgia Dept. of Public Health

  47. Resources • www.cdc.gov/flu/professionals • http://www.immunizationinfo.org/vaccines/influenza • http://www.health.state.ga.us/epi/flu/primer.asp • http://www.cdc.gov/flu/weekly/

  48. Surveillance(Extra Slides)

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