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Immunizations for Healthcare Workers . Texas Immunization Summit October 1, 2010 Christine B. Turley, MD Q.T. Box, MD Professor and Vice Chair for Clinical Services, Department of Pediatrics Scientist, Sealy Center for Vaccine Development

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immunizations for healthcare workers

Immunizations for Healthcare Workers

Texas Immunization Summit

October 1, 2010

Christine B. Turley, MD

Q.T. Box, MD Professor and Vice Chair for Clinical Services, Department of Pediatrics

Scientist, Sealy Center for Vaccine Development

University of Texas Medical Branch, Galveston


Financial Disclosures:

  • Commercial
    • I am a collaborator on vaccine studies in which my study group is supported by Wyeth, Merck and sanofi pasteur
    • I receive no industry salary support
  • NIH
    • I currently receive salary support from the NIH as PI on vaccine studies, including H1N1 vaccine, rotavirus vaccines, CMV vaccine and avian influenza vaccine
  • Discuss the case for Healthcare Workers (HCW) Vaccination
    • Influenza vaccine focus
  • Explore recommended strategies
  • Share success at one institution and review employed strategies
case for hcw vaccination
Case for HCW vaccination

Recommendations made by Advisory Committee on Immunization Practices (ACIP) and Healthcare Infection Control Practices Advisory Committee (HICPAC)

  • Based on exposure to, or possible transmission of, vaccine preventable diseases
    • Physicians, nurses, dental professionals, medical and nursing students, lab techs, administrative staff, first responders


  • Safeguard workers and protect patients
  • Eliminate or reduce susceptible employees
    • Resources and programs to manage exposures
hcw vaccine recommendations
HCW Vaccine Recommendations
  • Hepatitis B
  • MMR
  • Varicella
  • Tetanus, diphtheria, pertussis
  • Meningococcal
  • Influenza
current recommendations
Current recommendations
  • Hepatitis B
    • HCW—test 1-2 months after primary series or if have an exposure and not tested previously
  • MMR
    • Born > 1957, 2 dose series
    • Before 1957, consider vaccination if no proof of disease or immunity
  • Varicella
    • 2 dose series unless disease
current recommendations7
Current Recommendations
  • Td/Tdap
    • Booster of Td every 10 years
    • One time dose of Tdap ASAP to <65 year old HCW
  • Meningococcal
    • MCV4 to microbiologist staff <56 years old
    • MPSV4 to 56 and older
influenza vaccine
Influenza Vaccine
  • Recommended annually since 1986
    • Increased risk of exposure
      • Reduce staff illness and absenteeism
    • Known to spread from workers to patients
      • Vital to care of high risk patients
  • Recent emphasis on patient safety and quality measure for organizations
absenteeism of hcw
Absenteeism of HCW
  • Double blind, randomized, placebo controlled trial*
  • 2 large teaching hospitals over 3 years
  • Vaccinated vs. controls
    • Vaccinated group with lower incidence of influenza (1.7%) compared to controls (13.4%)
    • Estimated vaccine efficacy against serologically defined influenza A and influenza B infection of 88% and 89%
    • Trend toward
      • fewer total respiratory illnesses (28.7 per 100 persons) vs. controls (40.6 per 100 persons)
      • Fewer days of lost work (9.9 per 100 persons) vs. 21.1 per 100 persons for controls

*Wilde JA, McMillan JA, Serwint J, Butta J, O'Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281:908--13.

relationship of staff flu vaccination coverage and nosocomial infection with influenza
Relationship of Staff Flu Vaccination coverage and nosocomial infection with influenza*
  • Monitored for 12 years (‘87-99)
  • Coverage rated increased from 4% to 67%
  • Lab confirmed cases-staff
    • Dropped from 42% (1990-93) to 9% (1997-2000)
  • Nosocomial cases among hospitalized patients
    • Decreased 32% to 0 (p<0.0001)

*Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004;25:923--8.

patient outcomes
Patient outcomes

Most reported trials in nursing homes

  • Studies of staff vaccination have shown decrease mortality of residents 1, 2
  • One cluster randomized clinical trial3 with 44 nursing homes’ residents
  • When staff offered Vax (48% coverage) vs. not offered (6% coverage), impact on residents:
    • Decrease mortality
    • Decrease in ILI
    • Decrease in medical visits for ILI

1. Carman WF, et al. Lancet 2000;355:93--7.

2. Potter J, et al. J Infect Dis 1997;175:1--6.

3. Hayward AC, et al.BMJ 2006;333:1241.

regulatory encouragement
Regulatory “encouragement”
  • The Joint Commission on Hospital Accreditation1
    • 2006 started requiring organizations to offer influenza vaccine to employees, volunteers and licensed independent staff
    • Required to report their rate of vaccination and reasons for refusal to show work to improve the rate
  • State governments2
    • 7 states have laws requiring influenza vaccine be offered to HCW
    • Up to 25 have some sort of regulations applying to nursing home and/or acute hospitals
    • Some require declination forms to be signed if refused

1. Joint Commission standard IC.02.04.01


pre 2009 vaccination rates
Pre-2009 Vaccination Rates
  • 1989-20021
    • 10.0% 38.4%
    • No real increase after 1997
    • No difference based on type of HCW
  • 2004-20082
    • Health care workers-direct care 52.3%
    • HC support 32%
  • Overall never exceeded 49% in any season

1.Walker FJ, Singleton JA, et al. Influenza vaccination of healthcare workers in the United States, 1989-2002.

Infect Control Hosp Epid 2006:27(3); 257-265.

2. Caban-Martinez AJ, Lee DJ, Davila EP, et al. Sustained low influenza vaccination rates in US healthcare workers.

Prev Med 2010;50:210-2


One serosurvey* showed 23% of HCW had serologic evidence of influenza virus infection during a single influenza season

…the majority had mild illness or subclinical infection

*Wilde JA, McMillan JA, Serwint J, et al. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281:908--13.

cost effectiveness for healthy adults
Cost-effectiveness for healthy adults

Healthy adults (<65 years of age) savings include*:

  • 13%-44% fewer health-care provider visits
  • 18%-45% fewer lost workdays
  • 18%-28% fewer days working with reduced effectiveness
  • 25% decrease in antibiotic use for ILI
  • Savings categories
    • Reduction in direct medical costs
    • Decreased indirect costs from lost work productivity
      • >70% of cost savings

*Molinari NA, Ortega-Sanchez IR, Messonnier ML, et al. The annual impact of seasonal influenza in the US: measuring disease burden and costs. Vaccine 2007;25:5086--96.

can we afford not to vaccinate
Can we afford not to vaccinate?

Direct effects of HCW influenza infection

Increased morbidity of high risk patients

Increased morbidity of long term care facility residents

Personal effects

  • Indirect effects
  • Shortages of HCW
  • Disruption of normal functioning
  • Fewer elective admissions
  • Income loss to individuals due to


*Wilde JA, McMillan JA, Serwint J, et al. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281:908--13.

hcw vaccinations

HCW Vaccinations

What works?


What are barriers?

make it mandatory
Make it mandatory?
  • Several national organizations recommend mandatory vaccination
    • American Academy of Pediatrics,
    • National Patient Safety Foundation,
    • Society for Healthcare Epidemiology of America,
    • Infectious Disease Society of America
  • Others highly recommend
    • American Nursing Association
    • American Medical Association

It is projected that for herd immunity to have a benefit in the health care setting, achieving rates of at least 80% in HCW will be necessary.

hcw and high risk patient population attitudes beliefs
HCW and high risk patient population* -Attitudes/Beliefs-
  • HCW Vaccination rate 51%
  • Leading reasons:
    • Self-protection (77%)
    • Patient protection (49%)
  • Leading non-receipt reasons:
    • concerns about side effects (49%)
    • preventive quality (20%)
    • inconvenience (14%)

*LaVela SL, Smith B, Weaver FM, Legro MW, Goldstein B, Nichol K. Attitudes and practices regarding

influenza vaccination among healthcare workers providing services to individuals with spinal cord

injuries and disorders Infect Control Hosp Epidemiol. 2004 Nov;25(11):933-40..

rates with different interventions
Rates with Different Interventions

Talbot TR. Dellit TH. Hebden J. Sama D. Cuny J. Factors associated with increased healthcare worker influenza vaccination rates:

results from a national survey of university hospitals and medical centers. Infect Control Hosp Epidemiol. 31(5):456-62, 2010 May



  • risks of Influenza infection
  • risks and role of HCW in transmission
  • importance and risks of vaccination

Lack (or perceived lack) of readily available vaccine

outline of utmb effort 2009 10
Prior influenza campaigns included

Vaccine through Employee health

Limited unit based vaccine clinics

No active physician tracking

Outline of UTMB effort 2009-10
utmb hcw influenza vaccination experience non md
UTMB HCW Influenza Vaccination Experience (non-MD)

*Limited HCW staff due to Hurricane Ike

2009 2010 utmb
2009-2010 UTMB
  • Cornerstone of institutional Pandemic plan— Vaccination
    • Limited surge ability due to hurricane damage
    • Desire to create a cocoon
    • UTMB Vaccine Center Clinical Trials program participating in H1N1 Trials
utmb program 2009 10
UTMB Program 2009-10

H1N1 Vaccination Planning Committee

  • Educational marketing
  • Leadership endorsement
  • Physician champion--“Myth Buster”
  • Nurse Champions-local vaccinators
  • Easy access to vaccine
    • Targeted priority areas in waves
    • Local vaccination on units
  • Badges to identify those who have been vaccinated
  • Declination statements
    • Mandatory participation
    • Allowed active, local tracking
  • Wearing of surgical masks if decline
educational marketing
Educational Marketing
  • Multiple forums
    • Identification of Local Experts
    • Large and small groups
    • Targeted to HCW staff in priority areas
      • Pushing patient priority and staff priority
    • Web based presentations
    • FAQ’s about vaccination on website
    • Flu page
2009 2010 md h1n1 vaccination rates
2009-2010 MD H1N1 Vaccination Rates

Faculty physicians by area:

Resident physicians:

Overall 70%

campaign strengths
Campaign Strengths
  • Priority list for employees (OB and Pedi Employees, ER employees)
  • Instituted rapid vaccine screening questionnaire for eligibility
  • Badges to indicate H1N1 vaccination
  • Tracking and reporting in each department of priority employees
  • Active participation
  • Deadline for vaccination or declination
  • Required HCW to wear masks if declined
barriers to success
Barriers to Success
  • Local “pockets” of flu vaccine myths
  • New models of vaccine delivery
    • Additional staff
    • Staff flexibility
  • Garnering acceptance

of nasal vaccine

  • Reaching physicians
2009 2010 national results
2009-2010 national results*
  • By mid-January 2010, estimated vaccination coverage among HCW was
    • 37% for 2009 pandemic influenza A (H1N1)
    • 62% for seasonal influenza
    • 64% received either of these influenza vaccines
    • only 35% of HCW reported receiving both vaccines
  • Those who decline vaccination frequently express
    • doubts about the risk for influenza and the need for vaccination
    • are concerned about vaccine effectiveness and side effects
    • dislike injections

*CDC. Interim results: influenza A (H1N1) 2009 monovalent vaccination coverage---United States, October--December 2009. MMWR 2010;59:44--8.

take home message
Take Home Message

Emphasis on providing the safest, most effective means of keeping people well and helping those who are ill get better

  • Educate
    • Remember to answer the “WIFM” for each audience
  • Track success (individual accountability)
  • Convenience of vaccination
  • Desired outcome: protect patients (vaccine, masks)
  • Short of mandatory policy, results directly related to energy and emphasis put on the program