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S Carrots and Sticks: Influenza Vaccination of Healthcare Workers. Susan E Coffin, MD, MPH Children’s Hospital of Philadelphia July, 2011. Rationale behind HCW influenza vaccination Implementing a mandatory flu vaccination program at CHOP Impact of mandate HCW attitudes

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s carrots and sticks influenza vaccination of healthcare workers

SCarrots and Sticks:Influenza Vaccination of Healthcare Workers

Susan E Coffin, MD, MPH

Children’s Hospital of Philadelphia

July, 2011

Rationale behind HCW influenza vaccination

Implementing a mandatory flu vaccination program at CHOP

Impact of mandate

HCW attitudes

Nosocomial influenza rates

hcw flu vaccination background
HCW Flu Vaccination: background
  • Vaccination of health care workers (HCW) decreases…
    • Healthcare-associated influenza infection
    • HCW absenteeism
    • Secondary infections among HCW’s household contacts
  • Especially important in pediatric centers:
    • Large reservoir of disease in pediatric hospitals
    • Large proportion of hospitalized children at high risk of severe influenza
  • Growing interest in potential role of mandates
    • Recommended by the CDC and endorsed by IDSA, SHEA, AAP
    • Mandates successfully implemented at several other U.S. health systems
complications experienced by 56 patients with nosocomial influenza
Complications experienced by 56 patients with nosocomial influenza*

*2000-2004; complications determined by detailed chart review

Coffin, ICHE, 2009.

preventing nosocomial influenza why is hcw vaccination critical
Preventing nosocomial influenza: why is HCW vaccination critical?
  • Virus primarily transmitted by large respiratory droplets
    • Less benefit from hand hygiene
  • Virus can be shed 24 hrs before symptom onset
  • Adults can have asymptomatic infections
    • 20-50% of infected HCW were asymptomatic
  • Many hospitalized pediatric patients too young to receive vaccine or unable to mount protective immune response
vaccination reduces the rate of nosocomial influenza
Vaccination reduces the rate of nosocomial influenza
  • Observational study at University of Virginia hospital
  • Over 13 seasons
  • Increasing vaccination rate among HCW associated with reduced proportion of nosocomial influenza (32% in 1987-88 to 3% in 1998 -99)

Salgado, ICHE, 2004

improving hcw vaccination rates strategies that work
Improving HCW Vaccination Rates:Strategies that work
  • Education
    • Risks of disease1,2
    • Vaccine safety and efficacy2
  • Internal marketing1,3
  • Improving access to vaccine
    • Mobile carts1,2
    • Walk-in clinics, after-hours clinics2
  • Expanding responsibility
    • Vaccine deputies1
    • Charge nurses as educators2

1) Bryant, ICHE 2004; 2) Tapiainen ICHE 2005; 3) Spillman, 40th National Immunization Conference Atlanta, March 2006

cognitive dissonance 101
Cognitive Dissonance 101

Flu is bad for me and my patients.

I will get vaccinated.

Flu vaccine is unsafe.

Employer: “Get Vaccinated!”


I don’t get flu.

Flu vaccine doesn’t work.

I don’t get flu vaccine.

You Can’t Make Me!!!

wake forest declination form 2005
Wake Forest Declination Form (2005)

“I realize I am eligible for the flu shot and that my refusal of it may put patients, visitors, and family with whom I have contact, at risk should I contract the flu. Regardless . . .”

Adoption was associated with doubling of immunization rates (35% to 70% over 4 yr period)

Spillman SS presented at 40th National Immunization Conference Atlanta, March 2006

are declination forms enough
CONAre Declination Forms Enough?


HCW vaccination no longer a “passive decision”

Provides final opportunity to frame issue

Creates focus on individual accountability

  • Signals acceptance of non-vaccination
  • Polarizing effect reported by some
what level of hcw vaccination is ideal
What level of HCW vaccination is ideal?
  • Likely related to proportion of vaccinated staff and patients…
    • Retrospective study of 301 nursing homes (2004-2005)
    • Combined immunization rate of staff and residents inversely associated with risk of outbreak
    • 60% reduced risk of outbreak associated with staff immunization rates of 55% and resident immunization rates of 89% (OR 0.41; 95% CI 0.19, 0.89)

Shugarman, J Am Med Dir Assoc, 2006

vaccination of physicians
Vaccination of physicians

2007-2008 2008-2009

53% MD groups >80% (19/36)

22% MD groups fully vaccinated (8/36)

81% of MDs vaccinated (623/777)

16% MD groups >80% (5/31)

2009 2010 chop employee influenza vaccine program
2009-2010 CHOP Employee Influenza Vaccine Program

July, 2009: “The CHOP Patient Safety Committee recommends mandatory annual influenza vaccine for all staff* working in buildings where patient care was provided or whom provide patient care.”

*includes clinicians, support staff, volunteers, students; vendors informed of policy and asked to ensure compliance.

key strategies 2009 2010
Key Strategies, 2009-2010


  • Create accurate list of targeted staff and assure ability to provide timely, accurate reports
  • Establish method for evaluating requests for medical and religious exemptions
  • Determine timeline and educate
program timeline 2009 2010
Program Timeline, 2009-2010


  • 6 week program (9/15-10/31/09)
  • 2 week furlough for staff unvaccinated and without exemption as of 11/1/09
  • Termination if unvaccinated and without an exemption as of 11/15/09


  • 2 week extension due to delays in receipt of seasonal flu vaccine
what happened 2009 2010
What happened: 2009-2010
  • >9000 HCW vaccinated
  • 50 persons established medical exemptions
  • 2 persons established religious exemptions
  • 145 received temporary suspension
  • 9 persons terminated
labor relations 101
Labor Relations 101
  • 2 meetings to negotiate
    • Impasse declared
quotes from 10 26 09 negotiation
Quotes from 10/26/09 negotiation:
  • “You’re not making sure everyone who comes into CHOP is vaccinated.”
  • “Why can’t we just wear masks all winter?”
  • “No other institutions or regulatory groups support this.”
  • “This discriminates against employees who have less access to educational resources on the internet.”
labor relations 102
Labor Relations 102
  • Grievance filled (November, 2010)
    • CHOP: Termination for just cause
      • “Behaviors that are detrimental to the institution
      • “insubordination”
    • Union: Breech of contract
      • Not included in negotiated contract
findings and opinions from arbitration
Findings and Opinions from Arbitration:
  • “There can be no doubt that the Hospital had the right to promulgate a ‘reasonable’ rule/condition of employment that would better ensure the health and safety of CHOP’s patient population.”
  • “It is this Arbitrator’s finding that the policy implemented by the Hospital was reasonable in the context of the Hospital’s young, vulnerable patient community.”
year 2 experience 2010 2011
Year 2 Experience: 2010-2011
  • >9500 HCW vaccinated
  • Request for medical exemptions by 7 HCW (all granted)
  • Request for religious exemptions by 3 HCW
    • Review by retired judge
    • 2 granted, 1 denied
  • No suspensions or terminations.
evaluating impact of vaccine mandate
Evaluating Impact of Vaccine Mandate:


  • Cross-sectional study of a random sample of HCW subjected to the mandate
  • Anonymous 20 item questionnaire adapted from validated previously published instrument (electronic>>paper distribution)




25% clinical (n=1450)

8,093 HCW’s

study question what predicts agreement with the mandate
Study Question:What predicts agreement with the mandate?
  • Primary outcome: attitude towards influenza vaccine mandate
    • “Do you agree with CHOP’s policy that requires all health care workers to receive annual flu vaccination (a flu shot or the nasal spray vaccine) unless there is a medical or religious contraindication”
results survey
Results: Survey
  • Response rate (58%):
    • 1,388 respondents (total distributed = 2,443)
      • 657 (47%) clinical
      • 731 (74%) nonclinical
  • Respondent characteristics:
    • 77% female
    • 65% < 45 years of age
    • 68% have worked at CHOP <10 years
    • 90% staff previously vaccinated
  • 91% felt they had received info they needed from CHOP to make decision about flu vaccination
results reasons for vaccination
Results: Reasons for vaccination
  • Of those who had been vaccinated in past, majority of respondents cited:
    • Protection of self, family and patients
    • Job responsibility
    • Education received at work
  • Of those who declined flu vaccination in past, majority of respondents cited:
    • Not being at high risk
    • Fear of side effects
    • Belief that vaccine is not effective
results agreement with mandate
Results: Agreement with mandate
  • 77% respondents intended to be vaccinated before hearing about the mandate
  • 75% reported agreeing with mandate
  • 23% of respondents strongly considered declining the flu vaccine after hearing about the mandate
  • 72% reported agreeing that the mandate is coercive but almost everyone (96%) also agreed that mandatory policies are important for protecting patients
results agreement with mandate1
Results: Agreement with mandate
  • ~75% of both clinicians and non-clinicians agree that societal rights outweigh individual rights when it comes to vaccination
  • ~95% of both groups agree that parents have an obligation to make sure their children receive recommended vaccines
  • >95% of both groups agree with policies for requiring vaccination or screening for TB, HepB, measles, rubella and varicella
predictors of agreement with mandate
Predictors of Agreement with Mandate

Demographic Predictors

Attitudinal Predictors

  • Contact with high risk individuals at home or at work
  • Age
  • Amount of time working at CHOP
  • Gender
  • Previous receipt of flu vaccine
  • Previous experience with flu vaccine
  • Reasons for previous flu vaccine receipt
  • Reasons for previous flu vaccine declination
  • Attitudes towards influenza prevention
  • Intention to receive the vaccine before knowledge of the mandate
  • Attitudes towards other mandatory vaccination programs
  • Attitudes towards vaccines in general
possible implications
Possible Implications
  • Majority report that mandate is coercive
    • Does not appear to affect agreement with mandate
  • Factors associated with agreement with mandate represent attitudes and beliefs that may be modifiable through targeted outreach and educational activities
    • May need to focus upon different key themes for clinical and non-clinical staff
  • Reasons for previous declination of vaccination show that misconceptions regarding risk for infection and vaccine safety and efficacy do persist
    • Educational modalities may not be effectively communicating key messages
  • Nosocomial influenza poses a serious threat to hospitalized children.
  • HCW vaccination rates can be substantially improved through implementation of various voluntary measures.
  • Mandates may be required to achieve maximal levels of HCW compliance but many HCW may support mandates and believe that they are important way to protect patients and staff
  • Attitudes and beliefs associated with support of mandate may transcend professional role

Occupational Health

- Mary Cooney

Infection Prevention and Control

- Keith St. John

- Eileen Sherman

Infectious Diseases Epidemiology Research Group

- Kristen Feemster

- Priya Prasad

All CHOP Healthcare Workers