Transcript vaccination - Emergency Preparedness Resources for Home Care

Sarah DuVall, M.P.H.
Bureau of Immunization
New York State Department of Health
June, 2010
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.
2
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 2009
3
The Flu is a Serious Illness
 Flu is the 8th leading cause of death in the U.S.
CDC/ National Center for Health Statistics. Deaths and Mortality 2006.
 Flu kills as many or more Americans than breast cancer.
 Approximately 36,000 Americans will die because of the
flu this year.
Poland et al., Vaccine 2005;23:2251-5.
4
Influenza Disease Burden in the United States in
an Average Year
Deaths*
25,000 to 72,000
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.
5
Confirmed Influenza Outbreaks in
NYS Hospitals and LTCFs, by Year
NYSDOH
*Extended influenza season through August 2009.
6
Morbidity from Influenza Outbreaks in
NYS Hospitals and LTCFs, by Year
Number Ill
10000
8000
6000
Patients
Staff
4000
2000
0
'00-01 '01-02 '02-03 '03-04 '04-05 '05-06 '06-07 '07-08
Year
NYSDOH
'0809*
* Extended influenza season through August 2009.
7
Impact on Health Care Facilities
 Influenza is highly contagious.
 Can spread rapidly through a health care facility.
 Influenza is transmitted to patients by friends, family, and
health care personnel (HCP).
 Patients receiving home care services are at high risk of
complications from influenza due to their age and medical
conditions.
APIC Member Initiative Protect your patients. Protect yourself. 2004
8
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.
Poland et al., Vaccine 2005;23:2251-5.
9
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.
Weingarten, AJIC, 1989
 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
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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 legal and moral duties:
 Protection of personnel from risk of the work place.
 Protection of patients from risks posed by infectious
HCPs.
Decker MD, et al. Hospital Epidemiology and Infection Control 3rd ed.
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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
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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
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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).
Poland et al., Vaccine 2005;23:2251-5.
14
How to Prevent Influenza Infection
1. Implement policies that motivate HCPs to stay home when they
are sick.
2. 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.
3. The best protection is VACCINATION.
APIC Member Initiative Protect your patients. Protect yourself. 2004
15
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. 2009
16
Benefits of Influenza Vaccination
1. 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
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Benefits of Influenza Vaccination
2. 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.
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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
19
Month of Peak Influenza Activity
United States, 1976-2006
45%
50
45
There is usually ample time to
vaccinate HCP before
influenza occurs!
40
Percent
35
30
19%
25
20
13%
13%
15
10
3%
3%
Apr
May
5
0
Dec
MMWR 2007;55(RR-6):5
Jan
Feb
Mar
20
Vaccination Rates Need Improvement
 In 2006-07, only 44% of HCP were immunized against
influenza in the U.S.
 Includes all HCP who have contact with patients.
 Despite aggressive national efforts, rates of HCP immunized
have stayed around 40%.
MMWR.2009:58(early release): 1-52
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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
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Barriers to Vaccination
Primary Reasons
>30%
Reasons for Rejecting Vaccination
Among Health Care Personnel
Reason
Physician %
Nurse %
Technician
or Aide %
Admin.
Medical
Worker % Student %
Other %
Vaccine shortage
Concern about
side effects
Never get
influenza
Inconvenience*
57
40
58
53
34
48
17
34
36
25
23
28
14
25
27
18
23
22
26
9
4
7
34
13
Forgot
18
8
5
2
11
8
*Vaccine needs to be made available during all employment shifts.
Christini AB, et al. Infect Control Hosp Epidemiol 2007;28:171-7
Motivators for Vaccination
Primary Reasons
>60%
Reasons for Accepting Vaccination
Among Health Care Personnel
Reason
Fear of getting
influenza
Physician %
Nurse %
Technician
or Aide %
Admin.
Worker %
Medical
Student %
77
77
60
71
75
Fear of transmission
to patients
78
59
60
36
64
Vaccine is safe
77
56
42
38
63
Vaccine is effective
70
55
47
36
59
Vaccine was free
44
54
49
62
76
Close contact with
high risk person at
home
45
56
42
43
9
Convenient
28
38
44
45
53
Christini AB, et al. Infect Control Hosp Epidemiol 2007;28:171-7
Joint Commission Quality Measure
HCP Influenza Vaccination Levels
Standards for Influenza Vaccination Programs
in Accredited Institutions, 2007
1)
Annual influenza vaccination program that includes at least staff and licensed
independent practitioners.
2)
Provide access to influenza vaccination on-site.
3)
Educate staff and licensed independent practitioners about influenza
vaccination; non-vaccine control measures; and diagnosis, transmission and
potential impact of influenza.
4)
Annually evaluate vaccination rates and reasons for nonparticipation by staff
and licensed independent practitioners.
5)
Implement enhancements to the program to increase participation.
This standard is an accreditation requirement as of January 1, 2007.
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Improving Compliance
 Leadership Support
 Education
 Accessibility
 Incentives
 Feedback and Follow-up
 Mandatory Vaccination
 Measure Vaccination Rates
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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
27
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
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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
29
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
30
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.
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Mandatory Vaccination
Multiple groups support mandatory vaccination:
 New York State Department of Health
 American College of Physicians “An ethical obligation”
 Association for Professionals in Infection Control and
Epidemiology “HCP have an obligation…”
 Infectious Disease Society of America
“…likely to be the most effective means to protect patients against the
transmission of seasonal and H1N1 influenza by HCWs.”
 National Patient Safety Foundation
 U.S. Department of Defense (DOD)
 Mandatory seasonal influenza vaccination requirement for civilian health
care personnel who provide direct patient care in DOD facilities.
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U.S. Health Systems with HCP Influenza
Vaccination Mandates (4/10*)
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Battle Creek Health System, Battle Creek, MI
Barnes Jewish Corporation (BJC) HealthCare, St.
Louis, MO
Bronson Methodist Hospital, Kalamazoo, MI
Capital Region Medical Center, Jefferson City, MO
Children's Hospital of Orange County, CA
Children’s Hospital of Philadelphia
Children's Hospital of The King's Daughters Health
System, Norfolk, VA
Creighton University
Genesis HealthCare System, Zanesville, OH
Fort Walton Beach Medical Center, Fort Walton
Beach, FL
Hoag Hospital, Newport Beach, CA
Hospital of the University of Pennsylvania
Johns Hopkins Health System, MD
Kewanee Hospital, Kewanee, IL
Lakeview Medical Center, Rice Lake, WI
Long Beach Memorial Medical Center, Long Beach,
CA
Loyola University Health System, Chicago, IL
MedStar Health, Maryland and Washington, DC

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Michigan State University/Kalamazoo Center for
Medical Studies
Miller Children's Hospital, Long Beach, CA
New York-Presbyterian Hospital, New York
Orange Coast Memorial Medical Center, Fountain Valley,
CA
Pacific Hospital of Long Beach, CA
Petaluma Valley Hospital, Petaluma, CA
Saddleback Memorial Medical Center, Laguna Hills, CA
Saint Alphonsus Regional Medical Center, Boise, Idaho
Santa Rosa Memorial Hospital, Santa Rosa, CA
Spectrum Health Hospitals, Grand Rapids, MI
St. Joseph Health System, Orange, CA
St. Jude Medical Center, Fullerton, CA
Swedish Medical Center, Englewood, CO
Tri-Health, Good Samaritan and Bethesda North
Hospitals, Cincinnati, OH
UC ((University of California) Davis Health System,
Sacramento, CA
UC (University of California) Irvine Healthcare, Orange,
CA
Virginia Mason Medical Center, Seattle, WA
*http://www.immunize.org/laws/influenzahcw.asp
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Influenza Vaccination Coverage by
Employer Vaccination Policy, 2009
MMWR Vol. 59 / No. 12 April 2, 2010
34
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
35
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
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Purchasing Influenza Vaccine
Available Vaccines
 4 trivalent inactivated vaccines (TIV), administered
intramuscularly:
 Fluzone® - 6 mos and older
 FLUVIRIN® - 4 yrs and older
 FLUARIX™ - 18 yrs and older
 FluLaval™ - 18 yrs and older
 1 trivalent live, attenuated vaccine (LAIV) administered as
a nasal spray:
 FluMist® - healthy people 2 to 50 years old
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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
38
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.
 Nasal Spray (LAIV): Effectiveness in healthy adults
 Overall efficacy of LAIV and inactivated influenza vaccine in preventing;
laboratory-documented influenza, 85% LAIV and 71% TIV.
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.
39
Vaccine Information
Adverse Events
 Intramuscular Injection (TIV)





Local Reactions - 15%-20% (TIV)
Fever, malaise
- not common
Allergic reactions - rare (<1 in 1 million, Anaphylaxis)
Neurological
- rare (1 in 1 million, Guillain-Barre Syndrome)
U.S. Department of Health & Human Services Influenza Vaccination of Health-care Personnel 2008
 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.
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Neither LAIV or TIV Vaccines Can
Cause Influenza Disease
 TIV contains only non-infectious fragments of influenza
virus.
 LAIV cannot replicate in the lower respiratory track.
41
Influenza Vaccination Mandate
 SHRPC adopted an emergency regulation, 10 NYCRR, Subpart 66-3.
 Applied to HCP in certain Health Care Facilities.
 Direct patient contact
 Contact with those who have direct patient contact.
 ONLY medical exemptions allowed.
Began- August 13, 2009, effective immediately;
Suspended-October 23, 2009
Expired (no-renewal)-November 11, 2009.
Vaccination or provision of documentation no later than November
30 of each year
 New Employees- to be vaccinated November- April.
 NYSDOH is currently pursuing a permanenet regulation.

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42
Hospital Survey
 New York State (including New York City)
 211 Hospitals--------100% compliance
43
% of Health Care Personnel (HCP) Vaccinated in New York State
% of Health Care Workers Vaccinated
80%
72%
70%
60%
50%
46%
40%
35%
30%
20%
10%
0%
Seasonal 08-09
Vaccine Type
# of
Hospitals
Seasonal 08-09
Seasonal 09-10
H1N1 09-10
211
Seasonal 09-10
Vaccine Type
# of HCP
472,806
457,531
H1N1 09-10
# of HCP
Vaccinated
Mean # of HCP
Vaccinated
Range % of HCP
Vaccinated
201,118
953
0-93%
332,955
2,241
20-100%
125,590
2,168
0.01-100%
•66% increase in the # of HCP Vaccinated with the mandate in place.
•62% less HCP were vaccinated against H1N1 influenza than seasonal influenza.
• The % vaccinated is the same for Seasonal influenza and lower for H1N1 influenza.
45
% Medical Exemptions by % Vaccinated (Seasonal)
SeasonalExempt_percent
0.12
0.11
0.10
0.09
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0.00
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Seasonal_percent09
46
47
Reasons for Outliers
 High Medical Exemption Rates
 “Local physicians opposed the mandate”
 Problematic medical exemptions require follow up.
 Low Vaccination Rates
 HCP strongly opposed the mandate.
 HCP concerned about vaccine safety.
 Limited Vaccine Supply.
48
NYC
27%
Metro. (exc. NYC)
54%
NYS (exc. NYC & Metro)
19%
Metro Counties
Defined:
Nassau
Rockland
Suffolk
Westchester
49
% of HCP Vaccinated in NYS (non-NYC), NYC and Metro Counties
41%
46%
H1N1 09-10
28%
New York State (exc NYC)
16%
73%
74%
70%
68%
Seasonal 09-10
49%
51%
Seasonal 08-09
New York State (exc. NYC
and Metro)
New York City (NYC)
42%
39%
0%
10%
20%
30%
40%
50%
60%
% of Health Care Workers Vaccinated
Seasonal 08-09
Group
Metro(non-NYC)
# of
Hospitals
% Range
Mean %
Vaccinated
70%
80%
Seasonal 09-10
% Range
Mean %
Vaccinated
H1N1 09-10
% Range
Mean %
Vaccinated
NYC
57
9-86%
39%
20-100%
68%
0.1-40%
16%
Metro. (exc.
NYC)
41
0-71%
42%
34-98%
70%
8-100%
28%
NYS (exc. NYC
& Metro)
113
0-93%
51%
23-100%
74%
11-100%
46%
NYS (exc. NYC
& inc. Metro)
154
0-93%
49%
23-100%
73%
8-100%
41%
50
% of HCP with a Medical Exemption in NYS (non-NYC), NYC, and Metro Counties
Vaccine Type
0.88%
New York State (exc NYC)
1.04%
H1N1 09-10
0.43%
0.85%
New York State (exc. NYC
and Metro)
1.31%
1.35%
1.18%
1.38%
Seasonal 09-10
Metro(non-NYC)
New York City (NYC)
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
1.20%
1.40%
1.60%
% of HCP with a Medical Exemption
Medical Exemptions
Seasonal 09-10
Mean
Range%
H1N1 09-10
Mean
Range%
NYC
35
20-100%
22
0-9%
Metro (exc. NYC)
19
34-98%
7
0-3%
NYS (exc. NYC and Metro)
17
23-100%
12
0-11%
NYS (exc. NYC & inc. Metro)
17
23-100%
11
0-11%
51
Other Recommended Vaccinations
52
Vaccination of Health Care Personnel
HCP vaccination 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.
53
Other Valuable Resources

New York State Department of Health: Resources and Guidance –HCP Vaccination
http://www.nyhealth.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

U.S. Department of Health & Human Services:Toolkit-HCP Vaccination
http://www.hhs.gov/ophs/programs/initiatives/vacctoolkit/index.html

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.jcrinc.com/Audio-Conferences-Web-Conferences/Flu-Vaccination-Challenge/Resources/

U.S. Food and Drug Administration:Video-HCP Vaccination
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=81#4
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