Mandatory Influenza Vaccine for Healthcare Workers: Lessons from a Teaching Hospital

1. MANDATORY INFLUENZA VACCINE FOR HEALTHCARE WORKERS - Experience from a Large Urban Teaching Hospital Amy J. Behrman, MD Division of Occupational Medicine Department of Emergency Medicine University of Pennsylvania

2. University of Pennsylvania Health System • 3 Hospitals - 21,000 employees • HUP 800 beds • PAH 500 • PPMC 300 • 500,000 SF Ambulatory Practice/Surgery • Outlying practices t/o SE PA • >80,000 admissions; >2 million OPT visits • Operational and record-keeping challenges

3. HCWs and Vaccination - The view from Occupational Medicine • High volume OM practice primarily treating HCP • Injury and exposure management • Surveillance for TB and other conditions • Prevention of HAI by immunizing HCWs against vaccine-preventable diseases • Some (HBV) primarily for HCW protection • Most are vaccines against resp diseases (MMR, V, pertussis, influenza) that are a risk to vulnerable patients as well as HCP • None provide complete protection; all reduce the risk of transmission to HCP, HCP families, and especially to patients

4. HCWs and Vaccination • All these vaccines are recommended for HCWs - unanimous re CDC, JCAHO, SHEA, ACOEM, state DOHs • Some have been mandatory for years: • Measles, mumps, rubella • Some have been made mandatory more recently or not yet in healthcare settings: • Pertussis, varicella, influenza • My goals are to • Present our experience of these 2 approaches • Describe evolution of our current Flu program

5. HCWs and Vaccination- How are we doing? • Measles, mumps, rubella, varicella • HCP and patients are at risk if not immune • Long term immunity from disease or vaccine • Condition of employment, assessed at hire • Live virus vaccines with <100% efficacy • Vaccine risks exist • Medical contra-indications: Vaccines cannot be given to pregnant or immune-compromised HCP • HCW compliance approaches 100% • Religious objections: none in our setting

6. HCWs and Vaccination- How are we doing with flu? • Influenza • Killed vaccine safe, available and also recommended for HCWs for decades • Contact with infected HCWs is a risk for patients in acute care (Vanhems et al 2011) and chronic care (Carman et al 2000) • Few mandates in US, none until recently • National HCW rate averaged <50% • Quality focus for HUP OM since 2004

7. HUP Voluntary Influenza Vaccine Program 2004-2009 • Free vaccine available to all HCWs T/O Flu season • Vaccination on-site in all inpatient units, clinics and non-clinical sites, offered all shifts • Vaccine given to employees at cafeteria • Vaccine in public hospital areas via “Flu fairs” with educational materials, games, and incentives • Vaccine available on a walk-in basis in the OM clinic 8-12 hours/day. • Needle-free FluMist provided for medically eligible staff who preferred it.

8. HUP Voluntary Influenza Vaccine Program 2007-2009 • Declination forms analyzed to define HCW concerns • Influenza vaccine education via hospital newsletter, email, intranet, KL, and managers’ meetings. • Flu shot music video using hospital staff to address concerns about vaccine safety and efficacy based on previous declination forms: • http://www.youtube.com/watch?v=ruGgZbAVnko

9. HUP Voluntary Influenza Vaccine Program 2004-2009 • Although HUP OM and IC priority for many years • <45% until 2006-07 • 50% 2007-08 • 54% 2008-09 (60% of clinical staff)

10. HCWS AND INFLUENZA • Why is Flu different from other vaccine-preventable respiratory viruses? • Multiple hosts • Very high rate of genetic variability • Multiple seasonal strains circulate globally • Shed by droplets and contact • New strains arise frequently, varying in severity • Vaccine must be repeated yearly • Vaccine doesn’t always match circulating strains • Annual vaccine efficacy varies widely depending on match

11. Influenza strains can co-infect multiple species

12. HCWs and Influenza Vaccine • Probably even safer than other resp virus vaccines BUT • There is widespread, well-documented confusion among HCWs regarding • influenza morbidity and mortality • influenza vaccine efficacy and risk • There is widespread and well-documented resistance to influenza vaccine among HCWs in many countries • It is not often mandated by healthcare institutions

13. Resistance to Vaccination • Reasons HCW refuse Influenza Vaccine • Flu is not dangerous • Vaccine doesn’t work • Vaccine isn’t safe • Vaccine makes you sick • Access to vaccine • Fear of needles • Fear of Side Effects • Inconvenience • Hofmann, F. et al. “Influenza Vaccination of Healthcare Workers: a Literature Review of Attitudes and Beliefs.” Infection 34(3) 2006: 142-7.

14. Influenza in the US 200,000 hospitalizations per year Annual deaths range from 3,300-49,000 Severity varies with strains, which vary annually >90% are among the elderly People with underlying cardiac, pulmonary, immune disease are vulnerable Pregnant women are more likely to have severe illness, death, premature birth These are the groups most likely to be hospitalized and exposed to the risk of hospital-acquired infection. Young children were particularly vulnerable to severe illness from the H1N1 strain

15. Preventing Influenza Transmission • Vaccination is the most effective way to prevent transmission • Must be repeated to protect against each new year’s circulating strains • Decreased absenteeism in industry • Decreased infections in nursing homes • Decrease transmission to patients in healthcare settings

16. Preventing Influenza Transmission

17. Preventing Influenza Transmission • Although imperfect, vaccines remain a primary means of protection for HCWs in the community and workplace • Vaccination can protect patients, staff, families, and clinical unit function • Flu vaccination rates among HealthCare workers (HCW) are variable, with an average vaccination rate <50% • Should it be mandatory for HCPs?

18. Should Flu Vaccination be Required for HCWs?Pros and Cons • CON – • Nobody likes being forced - especially every year • Threatens HCW autonomy • May reduce efforts to educate HCWs & improve voluntary vaccination rates • Better multi-faceted voluntary programs can be created • May produce resentment and adversarial feelings - or worse • Expensive to monitor and enforce • Some voluntary programs have achieved >80% flu vaccine rates (Mayo) • ACOEM stance

19. Should Flu Vaccination be Required for HCWs?Pros and Cons • Pro • There may be real limits to effective voluntary programs effectiveness • Even 80% coverage rates don’t provide maximal risk reduction for patients and co-workers • Compliance for mandated MMRV immunity approaches 100% with negligible staff objections • Early mandatory influenza vaccine programs for HCWs reported >95% - essentially double prior rates

20. Should Flu Vaccine be Required for HCWs? 2007-2008 - Consensus among IC and OM staff 2008 Institutional debate and discussion of mandates to enhance patient and staff safety Early 2009 Leadership commitment Medical Boards- CMO Nursing Leadership - CNO Housestaff/GME Human Resources - CHROs Administration - EVP, Dean, Admin OGC

21. Should Flu Vaccine be Required for HCWs? HUP IM/EM Physician survey spring 2009 supported a mandatory vaccine policy (DeSante et al 2010) • 90% believed HCWs have an obligation to their patients to be vaccinated • 85% believed HCW vaccination should be mandatory • Those with more patient contact were more likely to be vaccinated, more likely to support mandates, and more likely to vaccinate their patients

22. HUP Voluntary Influenza Vaccine Program 2008-2009 • Declination forms analyzed to identify specific concerns to guide vaccine outreach efforts. • Free influenza vaccine available to all HCWs throughout the Flu season • Vaccination on-site in all inpatient units and clinics with additional immunization nurses rotating through all shifts, 7 days/week • Vaccine given to employees at stations in front of the cafeteria • Vaccine provided by OM nurses using a mobile cart to non-clinical as well as clinical areas on multiple days/shifts • Vaccine available in public hospital areas via “Flu fairs” which include educational materials, games, and incentives as well as flu shots. • Vaccine available on a walk-in basis in the OM clinic 8-12 hours/day. • Needle-free FluMist provided for medically eligible staff who preferred it. • Influenza vaccine campaign publicized in the hospital newsletter. • Influenza vaccine campaign publicized on the hospital intranet • Influenza vaccine campaign is publicized at managers’ meetings. • Flu shot music video using hospital staff and undergraduate singers created to address concerns about vaccine safety and efficacy based on previous declination forms: • http://www.youtube.com/watch?v=ruGgZbAVnko

23. HUP Influenza Vaccine Program2008-2009 • PROGRAM OUTCOMES 2008-2009 • 4th consecutive year of increased vaccination rates but only modest gains with great efforts at outreach • Infection Control and Occupational Medicine consensus on need for requiring vaccination • Nursing Leadership support for mandate • Physician Leadership support for mandate • HR Leadership support for mandate • OGC support for mandate

24. HUP Influenza Vaccine Program2009-2010 • New UPHS-wide policy requiring influenza vaccination for all HCWs • Scope: Staff, Physicians, Contractors, Volunteers, Students • Resources - supported by • Educational programs, website • Interactive live and electronic Q&A • Exemption reviews, medical and religious • Multi-faceted outreach to all staff @ all locations

25. HUP Influenza Vaccine Program2009-2010 • Exemptions • Medical: Notes from a treating physicians • Reviewed by designated MDs • F/u with exempting physicians and employees • Some allergy consults • Religious: Notes from clergy • Reviewed by multi-disciplinary & multi-denominational committee • Consequences • Compliance reporting from HRIS • Exempted staff masked during Flu season • Noncompliant staff suspensions and loss of raises

26. HUP Influenza Vaccine Program2009-2010 • Cough etiquette for patients and staff • Sick day utilization facilitated • Aggressive testing of HCW with ILI • Strict furlough for HCWs with Flu/ILI • Visiting age raised - unintended popularity of play area • Masking all ED patients and visitors

27. HUP Influenza Vaccine Program2009-2010 • Challenges • H1N1 influenza • 2 vaccines • Dual vaccine shortages & related triage/rationing • Sub-optimal database • Some skeptical and hostile staff - including clinicians

29. HUP Influenza Vaccine Program2009-2010 • Marked by some staff objections • Aided by public concern over H1N1 • Stressed by demand > supply in early season • Accepted as Patient Safety/Staff Safety initiative • 99.3% seasonal influenza vaccination • Plus 0.6% exemptions for HUP • 68.9% Compliance for H1N1 • 0.6% exemptions, prioritization of limited vaccine

31. HUP Influenza Vaccine Program 2010-2011 • Stable level of staff objection • Single vaccine; No supply issues • Decrease in public health and media • Accepted as Patient Safety/Staff Safety initiative • 99% seasonal influenza vaccination • Exemptions stable • <1% acute care • <2% nonclinical areas

32. HUP Influenza Vaccine Program 2010-2011 • Exemptions • Medical: Standardized Exemption/Education form • Reviewed by consistent designated MDs • Vigorous f/u with exempting physicians and employees • Increased allergy consults • Religious: Reviewed by CHRO • Consequences • Masking dropped for lack of evidence of efficacy • Exempted staff transferred from high risk areas - an unexpected source of compliance • Noncompliant staff faced suspension and loss of raises

33. Conclusions, Comments, Questions • Vaccines (incl flu) are effective in reducing risk of HAI for patients and staff (and community) • HAI, employee flu and absenteeism data inconclusive • Year to year variability accentuated by H1N1 • No known HAI Flu 2010-2011 • Many fewer HCWs with Flu - mostly “later” vaccinees • HCWs have a professional obligation to minimize these risks for patients (and colleagues) • Professionalism extends beyond direct clinical staff

34. Conclusions, Comments, Questions • Don’t even try to silence detractors and skeptics - Listen respectfully, respond rationally, discipline consistently • Misinformation and anxiety are common - perhaps most so for new and non-mandated vaccines • Mandates are the most effective way to maximize immunity for HCWs • Mandates may paradoxically allay anxiety among staff