S carrots and sticks influenza vaccination of healthcare workers
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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

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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

  • 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

Nosocomial Influenza at CHOP (2000-2006)

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?

  • 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

  • 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

Direct Benefits of HCW Vaccination

Talbot, ICHE, 2005

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

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)

“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?


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?

  • 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

Implementing Mandatory Influenza Vaccine at CHOP

Why CHOP HCW decline flu vaccine

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

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


  • 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


  • 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

  • >9000 HCW vaccinated

  • 50 persons established medical exemptions

  • 2 persons established religious exemptions

  • 145 received temporary suspension

  • 9 persons terminated

Labor Relations 101

  • 2 meetings to negotiate

    • Impasse declared

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

  • 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:

  • “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

  • >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.

Impact of a 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?

  • 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

  • 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

  • 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

  • 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 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

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

Factors associated with Agreement with Mandate: unadjusted results

Factors associated with Agreement with Mandate: multivariable model

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

Do Mandates Improve Patient Outcomes?


  • 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

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