Seasonal and H1N1 Influenza: National Healthcare Considerations and Vaccination Surveillance

1. Seasonal and H1N1 Influenza: National Healthcare Considerations and Vaccination Surveillance Tara MacCannell, PhD MSc Healthcare Epidemiologist, Division of Healthcare Quality Promotion, CDC

2. H1N1 Influenza Pandemic: Initial Timeline • Between April 15-17, 2009, • 2 cases of febrile respiratory illness • residents of adjacent counties in southern California • swine influenza A (H1N1) virus • Both viruses are genetically closely related to each other • resistant to amantadine and rimantadine • contain a unique combination of gene segments previously not recognized among swine or human influenza viruses in the United States • Neither child had contact with pigs

3. Early H1N1 Influenza Activity: Confirmed cases with known dates of illness onset, United States (as of April 27 2009) MMWR May 1, 2009 / 58(16);431-433

4. Early H1N1 Activity: Rapid Dissemination of Confirmed Cases in the Chicago Area, May 2009 Cumulative rates per 100,000 population of laboratory confirmed cases of 2009 H1N1 Influenza MMWR August 28, 2009 / 58(33);913-918

5. H1N1 Influenza Pandemic: Hospitalizations and Deaths by Age

6. Epidemiology/Surveillance Aggregate Hospitalizations and Deaths Reporting Activity (AHDRA) Influenza Week 52 – 8 JAN 2010 Weekly Lab-Confirmed Hospitalization Rate Hospitalizations per 100,000 Population Reporting Period End Date Excludes jurisdictions for which age distribution information is not available. Rate / 100,000 by Single Year Age Groups: Denominator source: 2008 Census Estimates, U.S. Census Bureau at: http://www.census.gov/popest/national/asrh/files/NC-EST2007-ALLDATA-R-File24.csv

7. Weekly Reported Lab-Confirmed Hospitalizations (n=46,992) H1N1 Interim Summary: Epidemiology/Surveillance Aggregate Hospitalizations and Deaths Reporting Activity (AHDRA) Influenza Week 52 – 8 JAN 2010 Hospitalizations (n) Reporting Period End Date

8. H1N1 Interim Summary: Epidemiology/Surveillance Aggregate Hospitalizations and Deaths Reporting Activity (AHDRA) Influenza Week 52 – 8 JAN 2010 Weekly Reported Lab-Confirmed Deaths (n=2,328) Deaths (n) Reporting Period End Date

9. Cumulative Influenza Hospitalization Rates by Age Group Emerging Infections Program (EIP) Network Influenza Week 52 – 08 JAN 2010 Hospitalizations per 100,000 Population Laboratory-confirmed influenza-associated hospitalizations are monitored using a population-based surveillance network that includes 10 EIP sites* in CA, CO, CT, GA, MD, MN, NM, NY, OR and TN, and 6 new sites† in IA, ID, MI, ND, OK and SD.

10. 2009 Influenza A (H1N1) Deaths Reported Current Week Deaths Reported Current Week 2009 Influenza A (H1N1) Deaths Reported Previous Weeks Deaths Reported Previous Weeks Number of Influenza-Associated Pediatric Deaths by Week of Death2006-2007 Season to Present Influenza Week 52 – 7 JAN 2010 • CDC received reports of 4 confirmed influenza-associated pediatric deaths during Week 52 (4 2009 H1N1) • The total number of confirmed H1N1 influenza-associated pediatric deaths since April 1, 2009 is 248 2009-10 Number of Deaths Reported=229 2007-08 Number of Deaths Reported = 88 2006-07 Number of Deaths Reported = 78 2008-09 Number of Deaths Reported = 130

11. Influenza Activity During Week 522008

12. Influenza Activity During Week 522009

13. H1N1 Influenza Pandemic: Recent Reported Activity by CSTE

14. National Summary Percentage of Visits for Influenza-like Illness (ILI) Reported by ILINetOctober 1, 2006 – January 2, 2010 Week 52 2009 Week 52 2006 Week 52 2008 Week 52 2007

15. Influenza Impact in the United States Annual Epidemics 5% – 20% of population infected ~ 36,000 deaths (90% in 65 and older) ~ 220,000 hospitalizations (50% in 65 and older) High illness rate in children High complication rate in elderly

16. Influenza Impact in the United States Annual Epidemics 5% – 20% of population infected ~ 36,000 deaths (90% in 65 and older) ~ 220,000 hospitalizations (50% in 65 and older) High illness rate in children High complication rate in elderly Pandemic Estimate† • 43 – 100 million infected • 89,000 – 207,000 deaths • 314,000 – 733,000 hospitalizations †Meltzer M, EID,1999;5

17. Influenza Impact in the United States Annual Epidemics 5% – 20% of population infected ~ 36,000 deaths (90% in 65 and older) ~ 220,000 hospitalizations (50% in 65 and older) High illness rate in children High complication rate in elderly • 2009 H1N1* • 14 – 34 million infected • 2,500 – 6,000 deaths • 63,000 – 153,000 hospitalizations • Higher mortality in young adults • Fewer cases in older adults Pandemic Estimate† • 43 – 100 million infected • 89,000 – 207,000 deaths • 314,000 – 733,000 hospitalizations *April to mid-October †Meltzer M, EID,1999;5

18. Reported Early Cases of Healthcare-associated H1N1 Influenza Transmission among Healthcare Personnel, n=12 Among confirmed and probable cases in adults aged 18--64 years and reported to CDC as of May 13, approximately 4% have occurred in HCP MMWR Weekly June 19, 2009 / 58(23);641-645

19. Challenges to Vaccination of Healthcare Workers: 2009 H1N1 Influenza vaccine and Seasonal Influenza vaccine uptake Survey Data on H1N1 Influenza Vaccination of Healthcare Personnel, 2009 MMWR Early Release, January 15, 2010

20. Epidemiology of Influenza • 15% persons ill average season • 75% of HCWs with ILI continue to work • 23% of HCP with serologic evidence of influenza infection (Wilde et al., 1997) • 59% could not recall having influenza • 28% could not recall any respiratory infection • Suggests high asymptomatic illness

21. Challenges to Influenza Vaccination among Healthcare Personnel • Approximately 9% of working adults in the United States are employed in healthcare settings • Transmission of influenza to patients by symptomatic and asymptomatic healthcare personnel has been previously demonstrated • Vaccination of healthcare personnel associated with lower absenteeism, illness, and influenza-related complications among at-risk persons • Vaccine uptake among healthcare personnel suboptimal (e.g. <50%), with newer data from Caban-Martinez et al (2010) suggesting 2004-2008 coverage estimates at • 52.3% vaccination by primary healthcare providers • 49% vaccination among healthcare technicians and practitioners • 36.6% vaccination among healthcare aides • 44.8% overall healthcare personnel

22. Facilitating factors Protect self Protect patients Convenience Peer influence Prior experience Barriers Concerns about vaccine safety or efficacy Not at risk (healthy immune system) Lack of understanding of transmission of influenza Fear of needles Not convenient Factors Influencing HCP Vaccination • Focused campaigns: 70-80% rates MMWR 2006 55:RR-2

23. A ten-year experience with seasonal influenza vaccination campaigns – successful interventions and barriers • Retrospective 10 year evaluation of flu vaccination rates in acute care, community and rural facilities • Association with bundles of interventions that increased compliance from 45% in 1997 to 72% in 2007, with 5/13 participating hospitals achieving >80% vaccination Ajenjo et al. ICHE March 2010. Vol 31, No 3

24. National Healthcare Safety Network (NHSN) • NHSN is an internet-based surveillance system that integrates the surveillance systems previously managed separately in the Division of Healthcare Quality Promotion (DHQP) at CDC • NHSN allows healthcare facilities to compare and benchmark metrics of healthcare safety

25. NHSN Patient Safety Component Healthcare Personnel Safety Component Blood/Body Fluid (BBF) Exposure Modules Influenza Modules BBF Exposure with Exposure Management Module Influenza Vaccination with (or without) Exposure Management Module FACILITIES MAY PARTICIPATE IN ONE OR MORE MODULES BBF Exposure Only Module Influenza Exposure Management Only Module

28. Introduction to NHSN’s Healthcare Personnel Safety Component • Launched in September 2009 • Continuation and expansion of the previous National Surveillance System for Healthcare Workers (NaSH) • Collect data from sample of US healthcare facilities • Estimate the severity and magnitude of adverse events among healthcare personnel • Estimate healthcare personnel participation in seasonal flu vaccine campaigns • Work toward prevention strategies to improve adverse events in healthcare personnel

29. Purposes of NHSN • Provide facilities with data that can be used for inter-facility comparisons and local quality improvement activities • Assist facilities in developing surveillance and analysis methods that permit timely recognition of patient and healthcare personnel safety problems and prompt intervention with appropriate measures • Conduct collaborative research studies with members

30. Staffing Requirements for Participating in the Healthcare Personnel Safety Component • Oversight of occupational health surveillance program by trained Occupational Health Professional (OHP), Infection Preventionist (IP) or Hospital Epidemiologist • Other personnel can be trained to • Screen for events (e.g., exposures, vaccinations) • Collect denominator data • Collect exposure management/vaccination data • Enter data • Analyze data

32. Challenges to Surveillance of Healthcare Personnel Injuries and Vaccine Coverage Influenza • NaSH collected numerator information but no adverse events or consistent denominators • Continuing reports of low compliance with yearly vaccination Blood/Body Fluid Exposures • Need for longitudinal surveillance with a commitment by facilities to provide denominators and data on post-exposure follow-up and seroconversion

33. Types of Data Entered in HPS • Healthcare worker demographics • Denominators • Measures of facility size (e.g., # beds, in-patient days, staffed beds) • Denominators for exposure rates, including facility size measures, numbers of HCP and FTEs

34. Updating HCP Immunization Recommendations • Update is currently in progress • Led by Immunization Services Division • Assisted by DHQP • Workgroup includes representatives from ACIP, HICPAC and CSTE • Tiered recommendations include diseases for which immunization is strongly recommended because of special risks for HCP • Hepatitis B, measles/mumps/rubella, varicella, influenza, (pertussis)

35. National Organizations HCP Influenza Vaccination Recommendations • IDSA, SHEA: mandatory with declination • ACIP 2007 • Level of vaccination coverage among HCP to be one measure of patient safety quality program • Implement policies to encourage HCP vaccination (e.g., obtain signed declinations) • Joint Commission 2005 • Vaccination offered to staff • ACOEM 2008 • Comprehensive approach including education, vaccination and infection control practices

36. Annual HCP Influenza Vaccination Efforts to Improve Coverage • State regulations and requirements targeting long-term care and other settings • Joint Commission requirements to offer vaccine to staff took effect for 2007-08 season • HHS Initiative and Toolkit • www.hhs.gov/ophs/programs/initiatives/vacctoolkit/ • National Influenza Vaccine Summit

37. Annual HCP Influenza VaccinationEfforts to Measure Coverage • Current estimates from National Health Interview Survey • Broad definition of healthcare occupation • Population-based estimates (not facility specific) • CDC/AHA survey conducted in 2006 found that all hospitals offered vaccine but ~1/3 did not measure coverage • Types of staff (employees vs. contractors, credentialed medical staff, students, volunteers) varied • Some excluded contraindicated persons and vaccine refusers from measurements • Joint Commission now requires annual evaluation of vaccination rates and reasons for non-participation Lindley M et al, CDC unpublished

38. Why use NHSN for monitoring influenza vaccination? • Systematic and standardized collection of information • Secure, confidential, electronic format • Compare facility data to national aggregate data • Free of charge • May already be implemented in your facility

39. Influenza Vaccination Module National-Level Purposes • Continue and expand occupational exposure and infection surveillance • Collect data from U.S. healthcare facilities to • estimate participation in flu vaccination campaigns • estimate the severity and magnitude of adverse reactions to flu vaccine among healthcare personnel (HCP) • monitor treatment and prophylaxis administered for influenza infections • Assess adoption and effect of strategies to increase vaccination uptake

40. Influenza Vaccination Module Facility-Level Purposes • Provide a record of flu vaccination and adverse reactions for HCP in the facility • Meet requirement for record-keeping for adult vaccine administration • Monitor trends in vaccination and declination rates • Monitor treatment and prophylaxis administered for influenza infections • Assess efficacy of facility influenza vaccination programs

41. Forms Used in the Influenza Vaccination Module • Pre- and Post-season Survey on Influenza Vaccination Programs for Healthcare Personnel • Healthcare Worker Demographic Data • Importing HCWs • Healthcare Worker Influenza Vaccination • Healthcare Worker Prophylaxis/Treatment • Other required forms • Facility Survey • Monthly Reporting Plan • Printable and web-based forms

42. Novel influenza A H1N1 enhancements • Non-seasonal influenza vaccination • Two doses • “Out of season” • Able to participate in anti-viral prophylaxis/ treatment surveillance only

43. To use or not to use NHSN? • Barriers to participation? • Human resources? • Electronic capability • Proprietary systems already in-use? • Web access? • Encourages participation? • Centralized database? • National/state-wide comparisons? • Data analysis capability?

44. Webcast Training

45. HPS Training Live web cast sessions Email and telephone support for surveillance and technical advice Online archived sessions and documents, including FAQs and newsletters Members meetings at national conferences Hands-on training* NHSN Members Conferences* *Planned

46. http://www.cdc.gov/nhsn/training.html

47. Support Email and telephone support for surveillance and technical advice NHSN: nhsn@cdc.gov Secure Data Network: 1-800-532-9929 or cdcsdn@cdc.gov NHSN Members website http://www.cdc.gov/ncidod/dhqp/nhsn_members.html Online manual and help messages

48. Potential Expansion of NHSN Capabilities • Immunization to other vaccine-preventable diseases • Immune status and prospective tracking of recommended vaccination series eg. hepatitis B, MMR, pertussis • Tracking of non-infectious injuries to healthcare personnel • Baseline exposures and seroconversions to infectious diseases ie. Tuberculosis

49. Thank you! fwu4@cdc.gov

50. HCW Influenza Demographic Data