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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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    1. SCarrots and Sticks:Influenza Vaccination of Healthcare Workers Susan E Coffin, MD, MPH Children’s Hospital of Philadelphia July, 2011

    2. Rationale behind HCW influenza vaccination Implementing a mandatory flu vaccination program at CHOP Impact of mandate HCW attitudes Nosocomial influenza rates Overview

    3. 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

    4. Nosocomial Influenza at CHOP (2000-2006)

    5. Complications experienced by 56 patients with nosocomial influenza* *2000-2004; complications determined by detailed chart review Coffin, ICHE, 2009.

    6. 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

    7. 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

    8. Direct Benefits of HCW Vaccination Talbot, ICHE, 2005

    9. 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

    10. 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!!!

    11. 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

    12. CON Are Declination Forms Enough? PRO 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

    13. 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

    14. Implementing Mandatory Influenza Vaccine at CHOP

    15. Why CHOP HCW decline flu vaccine

    16. 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)

    17. 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.

    18. Key Strategies, 2009-2010 PROGRAM ELEMENTS • 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

    19. Program Timeline, 2009-2010 PLAN: • 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 REALITY: • 2 week extension due to delays in receipt of seasonal flu vaccine

    20. What happened: 2009-2010 • >9000 HCW vaccinated • 50 persons established medical exemptions • 2 persons established religious exemptions • 145 received temporary suspension • 9 persons terminated

    21. Labor Relations 101 • 2 meetings to negotiate • Impasse declared

    22. 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.”

    23. 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

    24. 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.”

    25. 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.

    26. Impact of a Vaccine Mandate

    27. Evaluating Impact of Vaccine Mandate: METHODS: • 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) 50% non-clinical (n=1100) 25% clinical (n=1450) 8,093 HCW’s

    28. 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”

    29. 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

    30. 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

    31. 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

    32. 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

    33. 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

    34. Factors associated with Agreement with Mandate: unadjusted results

    35. Factors associated with Agreement with Mandate: multivariable model

    36. 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

    37. Do Mandates Improve Patient Outcomes?

    38. Summary • 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

    39. Questions?

    40. Acknowledgements: 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