A Unique Assessment of Hospital Employee Immunity Policies in Los Angeles County

1. A Unique Assessment of Hospital Employee Immunity Policies in Los Angeles County Vi Nguyen Los Angeles County Immunization Program

2. Why are Hospitals of Interest to Immunization Programs? 1997 ACIP and HICPAC report: • Health-care workers (HCWs) are at increased risk of acquiring and transmitting vaccine-preventable diseases (VPDs) - Physicians - Medical and nursing students - Nurses - Lab Technicians - Emergency medical personnel - Hospital volunteers - Dental professionals and students - Administration and support staff • Strongly recommended immunizations (or have documented immunity) for measles, mumps, rubella, hepatitis B, varicella, influenza

3. Why are Hospitals of Interest to the Los Angeles County Immunization Program? • Acute care hospitals report approximately 60% of VPDs to the Los Angeles County Immunization Program (LACIP). • In the event of a VPD case or outbreak, LACIP surveillance unit works very closely with hospital infection control practitioners (ICPs) to curtail further transmission.

4. Literature Review • Hospitals have not always considered the hospital occupation when designing infection control programs, which often results in policy and compliance differences between employment groups. (Lane NE et al., Pediatric Emergency Care 1997) • Hospital immunity policies often neglect to address each physician group individually (i.e., medical student, resident, hospital-based physician, and private or community physician), implying the potential for oversight in current hospital VPD surveillance methods. (Lane NE et al., Infection Control and Hospital Epidemiology 1997) • Types of patient services offered within a hospital can be a significant patient population indicator and can affect the design of hospital infection control programs. (Wurtz R, Infection Control and Hospital Epidemiology 1995)

5. 1989 survey From 1987-1989, 74 measles cases among LAC HCWs. Survey assessed: Existence of measles policy Existence of rubella policy Whether policy was mandatory Persons covered under policy Required proof of immunity 1992 survey Assessed changes from 1989 survey Existence of mumps policy Analyzed if hospital size and number of ICPs were associated with the existence of infection control policies Previous Los Angeles County (LAC)Hospital Surveys(Administered to acute care hospitals only)

6. 1989 Survey (n=102) 25.5% had measles policies 64.7% had rubella policies Only 3.9% had measles policies for all employees 93% of measles cases would be classified as immune based on birth before 1957 and oral history of disease/vaccination 1992 Survey (n=95) 58.9% had measles policies 72.6% had rubella policies 15.8% had mumps policies Only 4.2%, 4.2%, and 2.1% had measles, rubella, and mumps policies that covered all employees Significant association between hospital size/number of ICPs and existence of policies for rubella Key Findings from Previous LAC Hospital Surveys • Both studies recommended that immunity policies should cover all employees and that written documentation should be the only accepted proof of immunity.

7. Uniqueness of 2004 Study • Comprehensive examination of hospital infection control and employee immunity policies by VPD and hospital occupation • Inclusion of factors not previously considered • Predictor variables that would estimate likelihood of exposure among staff (size, services offered, cases/month) • Specific occupational categories • Specific infection control measures • Specific methods to monitor employee compliance • All LAC hospitals vs. acute care hospitals • Telephone interviews vs. self-administered questionnaires

8. Partial Purpose of 2004 Study • Examine VPD employee immunity policies currently in place in LAC hospitals • Information obtained from assessment can be applied to LACIP’s surveillance efforts to curtail VPD transmission • Assess whether tailored disease control/containment efforts are necessary in the event of a VPD exposure in a hospital

9. 2004 LAC Hospital Survey Research Questions For all LAC hospitals: • What, if any, immunity policies exist for hospital employees? • Are immunity policies enforced? • What are acceptable reasons for noncompliance with immunity policies? • Do immunity policies differ by VPD, hospital occupation, and hospital size?

10. VPDs Included on 2004 Survey • Measles • Mumps • Rubella • Hepatitis B • Varicella • Influenza

11. Hospital Occupations Included on 2004 Survey • Emergency room or urgent care physicians and nurses • OB/GYN physicians and nurses • Other hospital physicians and nurses • Residents • Medical school students • Hospital volunteers • Administrative staff • Other hospital employees (i.e., cafeteria workers, janitorial staff, lab technicians, security staff, etc.)

12. Methods

13. Key Definitions • Immunity = protection against infectious disease by either presence of antibody specific to each disease or assumed immunity via birth date or acquisition of natural/wild-type disease (A Dictionary of Epidemiology, Last 2001 and Medline Plus Medical Dictionary) • Immunity Policy = collection of rules and regulations established by this hospital to assess the immunity status of hospital employees or volunteers (Medline Plus Medical Dictionary, National Institutes of Health)

14. Result Categories • Characteristics of Responding Hospitals • Analysis of Existence of VPD-specific Employee Immunity Policies by Hospital Occupation • Policy in place • Mandatory policy • Effect of hospital services, adjusted by hospital size • Analysis of Methods to Determine and Monitor Employee Immunity Status • Analysis of Acceptable Reasons and Consequences for Noncompliance with Employee Immunity Policies

15. Characteristics of Responding Hospitals (n=93)

16. Result Categories • Characteristics of Responding Hospitals • Analysis of Existence of VPD-specific Employee Immunity Policies by Hospital Occupation • Policy in place • Mandatory policy • Effect of hospital services, adjusted by hospital size • Analysis of Methods to Determine and Monitor Employee Immunity Status • Analysis of Acceptable Reasons and Consequences for Noncompliance with Employee Immunity Policies

17. Existence of VPD-specific Employee Immunity Policies for Physicians and/or Nurses (n=93)

18. Existence of VPD-specific Employee Immunity Policies for Physicians and/or Nurses (n=93) Effect of Hospital Services on Policy Existence by Occupation, adjusted by hospital size OR (95% CI): * Significant OR for ER services 1 Physician clinics: 3.6 (1.1, 12.3) but wide confidence intervals 2 Physician clinics: 3.6 (1.2, 10.2) due to small sample size 3 Physician clinics: 6.6 (1.6, 26.6)

19. Existence of VPD-specific Employee Immunity Policies for Nurses Only

20. Existence of VPD-specific Employee Immunity Policies for Residents and Medical Students (n=93)

21. Existence of VPD-specific Employee Immunity Policies for Residents and Medical Students (n=93) Effect of Hospital Services on Policy Existence by Occupation, adjusted by hospital size OR (95% CI): * Significant OR for physician clinics but wide confidence intervals ** Significant OR for cancer treatment units but wide confidence intervals

22. Existence of VPD-specific Employee Immunity Policies for Non-medical Employees (n=93)

23. Existence of VPD-specific Employee Immunity Policies for Non-medical Employees (n=93) Effect of Hospital Services on Policy Existence by Occupation, adjusted by hospital size OR (95% CI): 1 Physician clinics: 3.4 (1.1, 10.9) 4 ER services: 3.5 (1.02, 11.7) 6 Physician clinics: 5.0 (1.6, 15.4) 2 Physician clinics: 4.8 (1.5, 15.5) 5 Physician clinics: 3.7 (1.3, 10.5) 7 Physician clinics: 6.1 (2.1, 17.2) 3 Physician clinics: 4.4 (1.4, 14.3) 8 Physician clinics: 3.4 (1.2, 9.3)

24. Result Categories • Characteristics of Responding Hospitals • Analysis of Existence of VPD-specific Employee Immunity Policies by Hospital Occupation • Policy in place • Mandatory policy • Effect of hospital services, adjusted by hospital size • Analysis of Methods to Determine and Monitor Employee Immunity Status • Analysis of Acceptable Reasons and Consequences for Noncompliance with Employee Immunity Policies

25. Methods to Determine Employee Immunity Status • For measles, mumps, rubella, hepatitis B, and varicella, most common methods were: • Serological screening (57.0% - 81.7%) • Documented Immunization record (26.9% - 30.1%) • Self-Reported Immunization (15.1% - 28.0%) • Self-Reported Disease History (11.8% - 19.4%) • Documented Disease History (6.5% - 8.6%) • Birth Prior to 1957 (5.4% – 7.5%) • 54.8% of hospitals had no methods for influenza

26. Measures Taken to Monitor Employee Immunity Status % of Hospitals With…. • Procedures for monitoring employees until proof of immunity demonstrated • Lowest: Influenza (16.1%) • Highest: Rubella (60.2%) • Measles, Mumps, Hepatitis B, Varicella (41.9% - 48.4%) • Program to provide vaccine at low or no cost to employees • Lowest: Mumps/Varicella 65.6% • Highest: Hepatitis B (98.9%) and Influenza (95.7%) • Measles and Rubella (68.8% - 72.0%)

27. Result Categories • Characteristics of Responding Hospitals • Analysis of Existence of VPD-specific Employee Immunity Policies by Hospital Occupation • Policy in place • Mandatory policy • Effect of hospital services, adjusted by hospital size • Analysis of Methods to Determine and Monitor Employee Immunity Status • Analysis of Acceptable Reasons and Consequences for Noncompliance with Employee Immunity Policies

28. Acceptable Reasons for Noncompliance with Employee Immunity Policies (n=93)

29. Effect of Hospital Size on Hospital Occupation Suspension/Termination for Noncompliance with Employee Immunity Policies (n=93) * non-significant OR

30. Comparison of 1989, 1992, & 2004 Data

31. Summary of Results – Part 1 • The existence of employee immunity policies differed by VPD. Rubella Hepatitis B Least Common Most Common Influenza Mumps Varicella Measles • The existence of employee immunity policies differed by hospital occupation.

32. Summary of Results – Part 2 • Hospital services having significant effects on VPD-specific employee immunity policies were ER services, physician clinics, and cancer treatment units. • The most accepted reason for noncompliance was medical contraindications [lowest: influenza (14%), highest: (hepB (29%)]. • Suspension/termination for noncompliance differed by occupation [lowest: medical students (11%), highest: other hospital employees (47%)]. • Larger hospitals were more likely than smaller hospitals to suspend/terminate other hospital physicians/nurses, volunteers, and administrative staff.

33. Conclusions • The lack of uniform policies across hospital occupation, VPD, and hospitals, along with inconsistent enforcement, require LACIP to tailor disease control/containment measures to individual hospitals in the event of a VPD exposure in the hospital. • We will be able to rank LAC hospitals by their overall level of infection control and employee immunity policies and share the results with the hospitals. • The ranking will invoke LAC hospitals to make changes to become more compliant with ACIP recommendations.

34. Limitations • Reporting bias • ICPs wanting to appear compliant with ACIP recommendations • Interview length (approximately 20 – 40 minutes) • ICPs rushing to complete the interview • “I don’t know” responses • Some ICPs worked at more than one hospital, but only one survey was administered to collect information on all hospitals assigned to the ICP. • Giving same responses for each hospital • Mixing up answers for hospitals • Some ICPs referred interviewers to the Employee Health Department when contacted for an interview.

35. Acknowledgements The survey design, implementation, and data analysis could not have been done without the hard work of the following individuals: Christina Mijalski Dulmini Kodagoda Marifi Pulido Martha Stokes Vichuda Lousuebsakul Jon La Mori

36. Immunization Program 3530 Wilshire Blvd Suite 700 Los Angeles, CA 90010 Phone # 213-351-7800 Fax # 213-351-2782 www.lapublichealth.org/ip/