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Influenza Media Teleconference February 14, 2006

Influenza Media Teleconference February 14, 2006. *Teleconference sponsored by GlaxoSmithKline. Why We Are Here Today. Facilitate roundtable discussion on the importance of healthcare worker immunization against influenza Overview of influenza virus

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Influenza Media Teleconference February 14, 2006

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  1. Influenza Media TeleconferenceFebruary 14, 2006 *Teleconference sponsored by GlaxoSmithKline

  2. Why We Are Here Today • Facilitate roundtable discussion on the importance of healthcare worker immunization against influenza • Overview of influenza virus • Impact of influenza outbreaks on healthcare setting • Benefits of influenza vaccination among healthcare workers • How media can help

  3. Society for Healthcare Epidemiology of America (SHEA) • Founded in 1980 to foster the development and application of the science of healthcare epidemiology • Organization’s mission is to advance the science of healthcare epidemiology through research and education and translate knowledge into effective policy and practice

  4. Introductions • Panelists • Trish Perl, MD, MSc • President, The Society for Healthcare Epidemiology of America (SHEA) • Kristin Nichol, MD, MPH • Professor of Medicine, University of Minnesota; Chief of Medicine & Director, Primary Care Service Line, Minneapolis VA Medical Center • Tom Talbot, MD, MPH • Assistant Professor of Medicine and Preventive Medicine, Associate Hospital Epidemiologist, Vanderbilt University School of Medicine • Ken Sands, MD • Health Care Quality, Beth Israel Deaconess Medical Center, Boston, MA

  5. Agenda • Overview of influenza virus (Dr. Nichol) • Complications, epidemiology and prevention • Influenza vaccination (Dr. Talbot) • Economic benefits • Risks associated with not vaccinating • Vaccination rates among healthcare workers • Current healthcare worker influenza vaccination rates (Dr. Sands) • Impact of healthcare setting outbreaks on healthcare community and patients • Benefits of healthcare worker vaccination

  6. Kristin Nichol, MD, MPHProfessor of MedicineUniversity of MinnesotaChief of Medicine & Director, Primary Care Service LineMinneapolis VA Medical Center

  7. Influenza Virus • Orthomyxovirus • Single stranded RNA virus (segmented genome) • Type A: • humans, animals, birds, more severe • Type B: • humans only, more common in children • Type C: • uncommon in humans • 2 surface glycoproteins • Hemagglutinin (HA) • attachment & entry • Neuraminidase (NA) • release Segmented genome HA NA Matrix protein M2 ion channel protein Influenza A Virus CDC. Influenza, The Pink Book, 8th ed. Cox, The Lancet 1999

  8. Epidemics, Pandemics and Antigenic Changes • Influenza viruses cause epidemics & pandemics • Size & relative impact result of • Antigenic variation, amount of immunity in populations & relative virulence • Antigenic variation result of changes in genes encoding for HA & NA • Drift – point mutations (both A & B) • Minor changes, same subtype • Associated with epidemics • Shift – genetic reassortment (A) • Major change, new subtype • Associated with pandemics CDC. Influenza, The Pink Book, 8th ed.

  9. Epidemic Influenza is a Common, Miserable, and Often Serious Illness • Acute respiratory illness • Abrupt onset of symptoms • Incidence: 5% to 20% of population • Higher in children • Serious fatality: 0.5 to 1 per 1000 • Higher in elderly • Spread by coughing and sneezing CDC: Influenza Fact Sheet. Glezen, PIDJ, 1997.

  10. Transmission of Influenza * Droplet * Aerosol * Direct Contact Bridges. Clin Infect Dis 2003; 1094. CDC. Influenza, The Pink Book, 8th ed.

  11. Presentation of Clinical Influenza Differs By Age Group ++++ Most frequent sign/symptom + Least frequent – Not found Cox NJ, Subbarao K. Lancet. 1999.

  12. Morbidity Associated with Influenza Episodes Kavet J. Am J Public Health 1977. Treanor, JAMA, 2000. Nichol, ICHE, 1997. The MIST Study Group, The Lancet, 1998.

  13. Influenza Illness – The Tip of the Iceberg Influenza Illness - Misery - Absenteeism - Physician Visits - Antibiotic Use - Hospitalizations - Deaths • Exacerbations of • chronic diseases • Secondary infections • Other CDC. Influenza, The Pink Book, 8th ed. Monto, Archives of Internal Medicine, 2000. MMWR 2005.

  14. Influence of Influenza Epidemics on Seasonal Mortality P & I Mortality All Cause Mortality Simonsen, Am J Public Health 1997.

  15. Average Number of Excess All Cause Deaths Attributable to Influenza US, 1990-1991 thru 1998-1999 Thompson, JAMA. 2003.

  16. Influenza-Associated Deaths are Similar to Other Important Causes of Deaths in Adults Influenza Range of VPD deaths in adults Adapted from: CDC, NCHS (online data for 2000); CDC Summary of Notifiable Diseases, US 2003; MMWR 52 (54) Apr 22, 2005 for 2003; CDC NVSS, Deaths: Final Data for 2000; 2002; 50 (15). Thompson, JAMA 2003.

  17. Epidemic Influenza Continues to Have a Huge Annual Impact • Cases: 25 – 50+ million cases • Days of illness: 100 – 200 million days • Work & school loss: Tens of millions • Hospitalizations: 85,000 – 550,000+ • Deaths: 34,000* – 51,000** • Costs: Billions of dollars Estimates for the U.S. + Ave respiratory & circulatory = 294,000 1979-80 thru 2000-01 * Ave all cause, 1976-77 thru 1998-99. **Ave all cause 1990-91 thru 1998-99. Thompson, JAMA 2003. Thompson, JAMA 2004. CDC, Influenza, The Pink Book, 8th ed. Pleis, American College of Physicians, 2002.

  18. Options for Preventing & Controlling Influenza • Hand hygiene • Respiratory hygiene / cough etiquette • Contact avoidance • Antivirals • Immunization CDC. Preventing the Flu 2006.

  19. Tom Talbot, MD, MPHAssistant Professor of Medicine and Preventive Medicine, Associate Hospital EpidemiologistVanderbilt University School of Medicine, Nashville, TN

  20. Influenza Vaccines • Types of influenza vaccines: • Inactivated (1968) • Live attenuated (2003) • Trivalent (covers 3 circulating strains) • Usually available in October annually • Work by stimulating antibody formation against viral surface proteins • Redosed annually because circulating virus may alter these proteins CDC. Influenza, The Pink Book, 8th ed. MMWR 2005. CDC Influenza Fact Sheet 2005.

  21. Comparison of Influenza Vaccines MMWR 2005.

  22. Cost/Benefit for Vaccination of Healthy Adults • Vaccination of healthy adults leads to • 13%–44% reduction in healthcare–provider visits • 18%–45% reduction in lost workdays • 18%–28% reduction in days working with reduced effectiveness • 25% reduction in antibiotic use for influenza-associated illnesses • Average annual savings of $13.66 per person vaccinated MMWR 2005.

  23. ACIP Target Groups for Influenza Vaccination • Groups at increased risk for influenza-related complications • Persons ≥ 50 years old • Residents of chronic care facilities • Persons with chronic medical disorders • Children/adults on long-term aspirin therapy • Children ages 6 to 23 months old • Women who will be pregnant during the influenza season MMWR 2005.

  24. ACIP Target Groups for Influenza Vaccination • Groups that can transmit influenza to high-risk persons • Employees of chronic care facilities • Home care providers • Household contacts (including children) of high-risk persons • Healthcare workers (HCWs) MMWR 2005.

  25. Why is Healthcare Worker Influenza Vaccination Important? • HCWs have frequent contact with patients at high-risk for influenza infection and its complications • HCWs can serve as a vehicle for spread of flu • HCW absenteeism can stress health system in times of community epidemics MMWR 2005. Talbot, ICHE 2005.

  26. Impact of HCW Influenza Vaccination Percent Reduction Talbot, ICHE 2005; Feery, JID 1979; Saxen, PIDJ 1999; Wilde, JAMA 1999; Carman, Lancet 2000; Potter, JID 1997.

  27. HCW Vaccination & the Impact Upon Patient Mortality Patient Mortality (%)

  28. Healthcare-Associated Influenza • Outbreaks reported in most care areas • HCW = culprit source • Influenza infection causes minimalorno symptoms in up to 25% of cases • Such workers still shed (and spread) virus • 76.6% HCW work while ill with influenza like illness • Worked mean 2.5 days while ill with influenza like illness CDC. Influenza, The Pink Book, 8th ed. MMWR 2005. Stott, Occup. Med. 2002. Talbot, ICHE 2005. Elder, BMJ 1996. Lester, ICHE 2003.

  29. Healthcare-Associated Influenza • Cases likely undetected because • Few cases for each exposure not noted as outbreak • Inpatients not tested for influenza • Shorter length of stay leads to discharge before symptom onset

  30. Not Setting a Good Example 2003: Only 40% of health-care workers were vaccinated Talbot, ICHE 2005. MMWR 2005.

  31. Neonatal ICUs Pediatric wards Adult transplant units Pediatric transplant units Infectious disease units General medical wards Location of Healthcare-Associated Outbreaks of Influenza • Geriatric wards • Long-term care facilities • Oncology units • Pulmonary rehabilitation centers • Emergency departments Talbot, ICHE 2005. Stott, Occup. Med 2002.

  32. Ken Sands, MDHealth Care QualityBeth Israel Deaconess Medical Center, Boston, MA

  33. The Healthcare Facility Experiencing an Influenza Outbreak • Can anticipate that the outbreak will last anywhere from a few days to months • Can expect 10-60% of HCWs to contract influenza • Can expect increased HCW absenteeism • May see attributable morbidity and death • Can anticipate additional patient carecosts that outweigh the costs of a HCW vaccination program Nichol, NEJM 1995. Salgado, The Lancet 2002.

  34. Illustrative Case: MortalityInfluenza Outbreak in a Neonatal Intensive Care Unit • 34 bed NICU in Hamilton, Ontario • Epidemic of Influenza A, January-May 1998 • 19 infants infected; one death • Vaccination rate among staff: 15% • Initial vector thought to be either a staff member or a visitor Cunney, ICHE 2000.

  35. Illustrative Case: HCW Role Influenza Outbreak in an Organ Transplant Unit • 12 Bed Transplantation unit in France • Over 4 days in January 2000, 4 confirmed patient cases • Only 1 of 4 patient cases had been visited by a non-HCW during the incubation period • 3 HCWs (11% of unit staff) with clinical diagnosis of influenza Malavaud, Transplatation 2001.

  36. Illustrative Case Report: HCW Attack Rates Influenza Outbreak in an Infectious Disease Unit • 23 bed AIDS/ID ward in Spain • Outbreak during a 16-day period in February 2001 • No community-based influenza activity at this same time Horcajada. Eur Respir J 2003.

  37. The Facility With a Strong Employee Vaccination Program • Is following a CDC recommendation for HCWs first established in 1981 • Based on studies of the general population, can anticipate lower absenteeism, less staff disruption, and lower health care consumption among its employees • May decrease patient mortality by as much as 40% (based on studies in the long-term care setting) Poland, Vaccine 2005. Nichol, NEJM 1995.

  38. Effectiveness of Influenza Vaccine in Healthcare Professionals • Two Baltimore Hospitals in early 1990s • 264 HCWs (mostly residents) • Random assignment to flu vaccine or controls Wilde, JAMA 1999.

  39. Mortality Benefit Demonstrated in Long-Term Care • 20 LTC facilities in the UK randomized to HCW vaccination or control Carman, The Lancet 2000.

  40. Reported Reasons for Low HCW Vaccination Rates Heimberger, ICHE 1995; Lester, ICHE 2003; Martinello, ICHE 2003; Nichol, ICHE 1997; Steiner, ICHE 2002; Weingarten, AJIC 1989.

  41. “I don’t want to catch the flu from a shot.” • Widely held belief (still) • Not supported by randomized clinical trials Nichol, NEJM 1995. CDC Influenza Q&A: Flu Shot.

  42. Methods to Improve HCW Vaccination Rates • Strong and visible administrative leadership • Visible vaccination of key leaders • Vaccination champions • Provision of adequate staff and resources  • Off-hours clinics • Use of mobile vaccination carts • Vaccination at staff/departmental meetings • Train the trainer programs that empower unit staff

  43. Methods to Improve HCW Vaccination Rates • Provision of vaccine free of charge   • Targeted education • Incl. dispelling of vaccine myths • Active declination for HCWs • Tracking of individual & unit-based HCW vaccination compliance • Surveillance for healthcare-associated influenza

  44. Can these Interventions Have an Effect? Vaccination Rate (%) NFID 2005. Salgado, The Lancet 2002. Virginia Mason Hospital Website.

  45. Larger Impact on Healthcare System • Decreased absenteeism means a more stable, more reliable workforce • Secondary impact of improved work conditions on patient safety

  46. In Summary • HCW vaccination is an imperative on either a clinical, economic, and ethical basis • The challenge is not whether to vaccinate, but how to ensure compliance

  47. Striving for Universal HCW Vaccination • Thought Leaders have taken this position in the academic literature • Virginia Mason Hospital: Instituted a vaccination requirement • As of 2005, seven states have enacted influenza vaccination mandates for healthcare workers in long-term care (with a few having mandates in acute care) Lester, ICHE 2003. APIC Website. Virginia Mason Hospital Website. Poland, Vaccine 2005.

  48. Closing Remarks

  49. Q&A Session

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