Influenza Vaccination of Health Care Personnel

1. Influenza Vaccination of Health Care Personnel Administrators and Program Managers New York State Department of Health, Bureau of Immunization –August 2012

2. Influenza (Flu) • The flu is a viral infection that can be caused by a number of different influenza strains. • The flu affects the lungs, throat, nose, and other parts of the body. • Unlike the common cold, the flu comes on suddenly, can make people very sick for a week or longer, and can send them to the hospital.

3. How Flu is Transmitted • Easily spread from person to person via respiratory droplets when an infected person coughs or sneezes. • Also spread when someone touches a surface contaminated with the virus. • Airborne transmission of the virus is possible, when an infected person is talking. • Adults shed the infectious influenza virus 1-2 days before any symptoms appear. CDC Epidemiology and Prevention of Vaccine-Preventable Diseases 2012

4. The Flu is a Serious Illness • Flu is the 8th leading cause of death in the U.S. • Flu kills as many or more Americans than breast cancer. • Approximately 36,000 Americans will die because of the flu this year. CDC/ National Center for Health Statistics. Deaths and Mortality 2009. Poland et al., Vaccine 2005;23:2251-5.

5. Influenza Disease Burden in the United States in an Average Year Deaths* 3,000 to 49,000 Hospitalizations* 117,000 to 816,000 Physician visits ~25 million Infections and illnesses 50 to 60 million * All-cause hospitalization and mortality associated with influenza virus infection. Thompson WW et al. JAMA. 2003;289:179-186; Thompson WW et al. JAMA. 2004;292:1333-1340; Couch RB. Ann Intern Med. 2000;133:992-998; Patriarca PA. JAMA. 1999;282:75-77; ACIP. MMWR. 2004;53(RR06):1-40; MMWR. 2010; 59(33): 1057-1062.

6. Confirmed Influenza Outbreaks in NYS Hospitals and Long Term Care Facilities (LTCFs), by Year NYSDOH *Extended influenza season through August 2009.

7. Morbidity from Influenza Outbreaks in NYS Hospitals and LTCFs, by Year NYSDOH * Extended influenza season through August 2009.

8. Impact on Health Care Facilities • Influenza is highly contagious. • Can spread rapidly through a health care facility. • Influenza is transmitted to patients by other patients, visitors, and health care personnel (HCP). • Patients in health care facilities are at high risk of complications from influenza due to their age and medical conditions. APIC Member Initiative Protect your patients. Protect yourself. 2004

9. Impact on Health Care Facilities • Up to ¼ of HCP contract influenza each season. • A CDC hospital survey conducted during flu season showed the following: • 35% reported staffing shortages. • 28% reported bed shortages. • 43% reported ICU bed shortages. • 9% reported diversion of patients to other facilities. Poland et al., Vaccine 2005;23:2251-5.

10. Role of HCP in Nosocomial Transmission of Influenza • Many HCP work while ill with influenza like illness (ILI). • >75% MDs and RNs surveyed reported working while ill with an ILI. • 37% of residents worked while ill with ILI. • Otherwise healthy adults may experience minimal symptoms but shed, and transmit, influenza virus. • >25% who seroconverted did not recall an ILI or any respiratory tract illness. Foy, Am J Epi, 1987 Weingarten, AJIC, 1989

11. Essential Component of a Health Care Institution’s Occupational Health Program • Ensure the immunity of HCP to infections or diseases caused by relevant infectious agents. • Two fundamental legaland moralduties: • Protection of personnelfrom risk of the work place. • Protection of patientsfrom risks posed by infectious HCPs. Decker MD, et al. Hospital Epidemiology and Infection Control 3rd ed.

12. Definition of HCP and Facility • Those with direct patient care: MDs, RNs, nursing assistants, therapists, technicians, emergency personnel, dental personnel, pharmacists, lab personnel, autopsy personnel, students, trainees, volunteers. • “Those not directly involved with patient care but potentially exposed to infectious agents that can be transmitted to and from HCP,” such as clerical, dietary, housekeeping, and maintenance staff. Influenza Vaccination of Health-Care Personnel Recommendations of ACIP and HICPAC-MMWR 2006

13. Definition of HCP and Facility (con’t) • Facilities include “acute care hospitals, nursing homes, skilled nursing facilities, physician’s offices, urgent care centers, and outpatient clinics, and to persons who provide home health care and emergency medical services.” Influenza Vaccination of Health-Care Personnel Recommendations of ACIP and HICPAC-MMWR 2006

14. All HCP Should Be Vaccinated • Regardless of their employment status. • Includes HCP with direct contact with patients (e.g., nurses, technicians, physical therapist, physicians, students). • Includes HCP without direct patient care responsibilities (e.g., environmental service worker, security, contract service workers, emergency medical personnel).

15. How to Prevent Influenza Infection • Implement policies that motivate HCPs to stay home when they are sick. • Encourage appropriate infection control techniques. but this is not enough…… • HCP can still spread the flu even when they DON’T feel sick. • 50% of infected people don’t have symptoms when they are infected. • All individuals are contagious for at least 1 day before they have symptoms. • The best protection is VACCINATION. APIC Member Initiative Protect your patients. Protect yourself. 2004

16. Why Vaccination of HCP Works • Vaccination is most effective in younger, healthier individuals. • 70%-90% effective among healthy persons <65 years of age. • Patients at highest risk, including the elderly and the immunocompromised, are least likely to develop an adequate response to the vaccine. • 30-40% effective among frail elderly persons. Therefore, vaccination of those individuals who come in contact with our vulnerable population is the most effective strategy for prevention. APIC Member Initiative Protect your patients. Protect yourself. 2004 CDC Epidemiology and Prevention of Vaccine-Preventable Diseases. 2012

17. Benefits of Influenza Vaccination • Reduction in nosocomial influenza and influenza-related deaths. • Over 12 years in one hospital, vaccination coverage increased from 4% to 67%. • Laboratory-confirmed influenza cases among HCP decreased from 42% to 9%. • Nosocomial cases among hospitalized patients decreased 32% to 0 (p<0.0001). Salgado et al., Inf Cont Hosp Epi 2004;25:923-8 • Two randomized controlled trials evaluated impact of HCP influenza vaccination on residents in nursing homes. • They estimated >40% decrease in overall mortality among residents in the setting of high employee vaccination levels, regardless of patient vaccination levels. Carman et al., Lancet 2000;355(9198): 93—7 Potter, et al., J Infect Dis 1997;175:1--6

18. Benefits of Influenza Vaccination • Reduction in staff illness and illness related absenteeism. • Workers who receive influenza vaccine take approximately 50% fewer sick days. • Replacement workers can result in increased expenses caused by decreased productivity, increased medical errors, and disrupted work environments. • Staff shortages can be exacerbated by influenza outbreaks. APIC Member Initiative Protect your patients. Protect yourself. 2004 • Double shifts increase the probability of medical errors. The cost of promoting and delivering vaccinations to health care personnel is lower than the costs associated with influenza illness. Burls et al., Vaccine 2006;24:4212-21.

19. Reduction in the Incidence of Influenza Infection and Related Issues in HCP Receiving Vaccination Massachusetts Medical Society, Masspro, MDPH Employee Flu Immunization Campaign Kit 2006

20. Month of Peak Influenza Activity United States, 1976-2006 There is usually ample time to vaccinate HCP before influenza occurs! MMWR 2007;55(RR-6):5

21. Vaccination Rates Need Improvement • In 2010-11, only 63.5% of HCP were immunized against influenza in the U.S. • Despite aggressive national efforts and increased attention to influenza, rates of HCP immunized remain well below the Healthy People 2020 target of 90%. MMWR 2011;60(32):1073-1077.

22. Percentage of Hospital HCP Vaccinated with Flu Vaccine in NYS, 2008 - 2012 Source: NYSDOH Hospital Health Care Worker Vaccination Survey, 2009-2012 (unpublished data).

23. Percentage of Long Term Care Facility HCP Vaccinated with Flu Vaccine in NYS, 2008 - 2012 Source: NYSDOH Influenza and Pneumococcal Immunization Data Report for Long Term Care Facilities, 2009-2012 (unpublished data).

24. Barriers to Vaccination • Reasons HCP decline influenza vaccination: • Misconception that vaccination can cause influenza (10-45%). • Fear of adverse events (8-54%). • Times/locations of vaccination were unsuitable (6-59%). • Perception that they are not at risk (6-58%). • Fear of injections (4-26%). • Lack of vaccine efficacy (3-32%) - except physicians. • Doubt that influenza is a serious disease (2-32%). • Two main barriers: • Misperception of influenza, its risks, the role of HCP in its transmission to patients, and the importance and risks of vaccination. • Lack of (or perceived lack of) conveniently available vaccine. • Hofman et al., Infection 2005;34:142-147

25. Reasons for Rejecting Vaccination Among Health Care Personnel Barriers to Vaccination Primary Reasons >30% *Vaccine needs to be made available during all employment shifts. Christini AB, et al. Infect Control Hosp Epidemiol 2007;28:171-7

26. Reasons for Accepting Vaccination Among Health Care Personnel Motivators for Vaccination Primary Reasons >60% Christini AB, et al. Infect Control Hosp Epidemiol 2007;28:171-7

27. Joint Commission Quality MeasureHCP Influenza Vaccination Levels Standards for Influenza Vaccination Programs in Accredited Institutions, 2007 • Annual influenza vaccination program that includes at least staff and licensed independent practitioners. • Provide access to influenza vaccination on-site. • Educate staff and licensed independent practitioners about influenza vaccination; non-vaccine control measures; and diagnosis, transmission and potential impact of influenza. • Annually evaluate vaccination rates and reasons for nonparticipation by staff and licensed independent practitioners. • Implement enhancements to the program to increase participation. This standard is an accreditation requirement as of January 1, 2007.

28. Improving Compliance • Leadership Support • Education • Accessibility • Incentives • Feedback and Follow-up • Mandatory Vaccination • Measure Vaccination Rates

29. Leadership Support • Leadership involvement is essential for a successful program. • Leadership is responsible for: • Establishing expectation that influenza vaccination of HCP is a patient safety issue. • Making sure vaccination program has adequate resources. • Reducing or eliminating barriers. • Being a role model. CDC and The Joint Commission Improving Your Vaccination Program 2009

30. Education • HCP need to know when and where education and vaccinations will be offered and the importance of the vaccination. • Promoting vaccinations can take many forms in many venues, including: • E-mail notice and reminders. • Newsletters, with regular updates. • Posters.* • Screen savers. • Stickers worn by health care personnel.* • Messages delivered in person at meetings or health fairs.* *NYSDOH and the CDC offer FREE materials, www.nyhealth.gov/www.cdc.gov CDC and The Joint Commission Improving Your Vaccination Program 2009

31. Accessibility • Provide free vaccines at work. • Use leaders as supportive role models. • Use vaccination clinics, mobile carts. • Link vaccinations to required activity. • Mandatory tuberculin skin testing. • Annual safety competency or skills days. • Disaster drills. CDC and The Joint Commission Improving Your Vaccination Program 2009

32. Incentives for HCPs • Financial incentives (discounts on benefits, impact on merit increases, consideration in granting decisions regarding time off). • HCP recognition. • Need to understand HCPs motivation. CDC and The Joint Commission Improving Your Vaccination Program 2009

33. Feedback and Follow-up • Review list of non-vaccinated employees weekly. • Provide weekly reminders to supervisors with list of non-vaccinated employees. • Identify central authority figure to add pressure to comply. Buy-in from administration is key. • Put pressure on employee to make active decision, instead of allowing passive avoidance. • Continue until goals are met. McCullers JA, et al., Inf Cont Hosp Epi, 2006;27:77-9.

34. Mandatory Vaccination Multiple groups support mandatory vaccination: • American Academy of Pediatrics • American College of Physicians • American Hospital Association • American Medical Directors Association • American Pharmacists Association • American Public Health Association • Association for Professionals in Infection Control and Epidemiology

35. Mandatory Vaccination, continued • Infectious Disease Society of America • National Business Group on Health • National Foundation for Infectious Diseases • National Patient Safety Foundation • Society for Healthcare Epidemiology of America • U.S. Department of Defense (DOD)

36. Influenza Vaccination Coverage by Employer Vaccination Policy, 2009 MMWR 2011; 60(32):1073-77.

37. Measure HCP Vaccination Rates • Measurement is essential to your program. • Only through measurement is it possible to determine if performance is getting better, worse, or staying the same. • Capture alternative administration (for example: clinics, physician offices, pharmacies, etc.). CDC and The Joint Commission Improving Your Vaccination Program 2009

38. Purchasing Influenza Vaccine • Pre-book vaccine in January or February. • Influenza vaccines take months to produce. • Vaccine manufacturers are hesitant to risk producing products they will be unable to sell. • For more information on distributors and influenza vaccine availability, please visit the following websites: • Influenza Vaccine Distributor Information http://www.flusupplynews.com/resources.cfm • Influenza Vaccine Availability Tracking System (IVATS) http://www.preventinfluenza.org/ivats/ivats_healthcare.asp

39. Purchasing Influenza Vaccine The following vaccines will be available for ADULTS: The following vaccines will be available for CHILDREN:  • Afluria • Agriflu • Fluarix • FluLaval • FluMist • Fluvirin • Fluzone • Fluzone High-Dose • Fluzone Intradermal • Afluria • Fluarix • FluMist • Fluzone • Fluvirin

40. Vaccine Information Using Nasal Spray (LAIV ) • LAIV may be used for healthy, non-pregnant HCP <50 yrs old. • At times of vaccine shortage, LAIV is “especially encouraged” unless contraindicated. • HCP who work with severely immunocompromised patients in a protected environment should NOT receive LAIV (bone marrow transplant unit staff). • LAIV can be used to vaccinate HCP who have close contact with persons with a lesser degree of immunosuppression (e.g., persons with diabetes, persons with asthma taking corticosteroids, or persons infected with HIV). Transmission of LAIV has NEVER been documented in a health care facility. CDC and The Joint Commission Improving Your Vaccination Program 2009

41. Vaccine Information Intradermal (ID) influenza vaccine • Licensed in May 2011. • For use in adults ages 18-64 years. • Alternative to TIV – no preferential recommendation. • Less antigen and smaller volume than in TIV. • Very fine needle – 90% smaller than the needles used for regular flu shots. • Single dose, preservative-free, prefilled syringe. • Delivers the vaccine into the dermal layer of the skin. • The dermal layer contains a high concentration of specialized cells, known as dendritic cells, which play a key role in generating an immune response. MMWR 2011; 60(33): 1128-1132.

42. Vaccine Information Efficacy • Intramuscular Injection (TIV): Effectiveness in adults < 65 years • 80% (95% CI 56% to 91%) when vaccine matched circulating strain. • 50% (95% CI 27% to 65%) when not well matched. Jefferson, et al. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001269. • Intradermal Injection (ID): Effectiveness in adults 18 – 64 years • Similar efficacy to TIV against influenza A (H1N1), A (H2N3) and B strains. Sanofi Pasteur, Inc. Fluzone [package insert]. 2011 • Nasal Spray (LAIV): Effectiveness in healthy adults • 85% overall efficacy in preventing laboratory-documented influenza. Treanor et al., Vaccine 1999;18:899—906. • Even with suboptimal vaccine-wild virus match: • 24% fewer febrile upper respiratory illness episodes (URI). • 27% fewer lost work days due to febrile URI. • 41%-45% fewer days of antibiotic use. Nichol et al., JAMA 1999;282:137—44.

43. Vaccine InformationAdverse Events • Intramuscular Injection (TIV) • Local Reactions: • pain 20-50% • redness 10-13% • swelling 6-8% • Muscle aches: 18-30% • Headache: 14-30% • Malaise: 14-22% • Fever: 2-3% Sanofi Pasteur, Inc. Fluzone [package insert]. 2011 • Allergic reactions: <1 in 1 million • Guillain Barre Syndrome: 1 in 1 million MMWR 2010; 59(RR-8) • Intradermal (ID) • Local Reactions: • redness 76% • hardness 58% • swelling 57% • pain 51% • itching 47% • Systemic side effects: similar to TIV Sanofi Pasteur, Inc. Fluzone [package insert]. 2011 • Nasal Spray (LAIV) • Local Reactions: • cough 14% • runny nose 45% • sore throat 28% • chills 9% Belshe RB et al. Clin Infect Dis 2004;39:920--7.

44. Neither TIV, ID, nor LAIV Vaccines Can Cause Influenza Disease • TIV and ID contain only non-infectious fragments of influenza virus. • LAIV cannot replicate in the lower respiratory tract.

45. Other Recommended Vaccinations

46. Vaccination of Health Care Personnel HCPvaccination is an essential line of defense to prevent the spread of infections: • to and from patients to HCPs, • among HCPs, and • from HCPs to patients. Decker MD, et al. Hospital Epidemiology and Infection Control 3rd ed.

47. Other Valuable Resources • New York State Department of Health: Resources and Guidance –HCP Vaccination http://www. health.ny.gov/prevention/immunization/health_care_personnel/ • Centers for Disease Control and Prevention-Resources and Guidance-Health Care Personnel Vaccination http://www.cdc.gov/vaccines/spec-grps/hcw.htm • Association for Professionals in Infection Control and Epidemiology: Toolkit-HCP Vaccination http://www.apic.org/Content/NavigationMenu/PracticeGuidance/Topics/Influenza/toolkit_contents.htm • The Joint Commission: FREE-PODcasts, audio conference and additional resources-HCP Vaccination http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=81#4 • U.S. Food and Drug Administration: Video-HCP Vaccination http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=81#4

48. Questions