# Presentation: 209552

## Influenza Vaccination of Health-care Personnel:Disease, Vaccine, Beliefs, Barriers,and Recommended Strategies to Improve VaccinationAdapted from presentations by Gina T. Mootrey, DO, MPH and William Atkinson, MD, MPH, Centers for Disease Control and Prevention

## HHS Initiative for Influenza Vaccination of Health Care Personnel:  Components

**Two components**
**Improving HHS health care employee influenza vaccination, with focus on**
**Federal Occupational Health**
**Indian Health Service**
**U.S. Public Health Service Commissioned Officers **
**NIH Clinical Center**
**CDC**
**Promoting influenza vaccination to non-federal health care organizations and HCP**

**Notes:**
The Department has begun an initiative to improve health care personnel vaccination
Internally with HHS HCP, particularly at Federal Occupational Health, the Indian Health Service, U.S. Public Health Service Commissioned Officers, the NIH Clinical Center, and CDC.  

In addition, we are planning outreach to the non-federal community of health care personnel.

## HHS Initiative for Influenza Vaccination of Health Care Personnel:  HHS Employees

**Three focus areas**
**Developing office and agency specific strategies to improve HCP vaccination levels**
**Measuring employee vaccination rates**
**Disseminating a toolkit containing**
**Standard presentation**
**Relevant articles**
**Posters**
**Fact sheets, questions and answers**
**Vaccine information statements**
**Links to other resources**
**Toolkit will be available on HHS OPHS website**

**Notes:**
The internal HHS influenza vaccination effort has three focus areas:  1) developing at least two specific office and agency strategies to improve vaccination levels, 2) measuring employee vaccination rates, and 3) disseminating a toolkit, that will include a standard slide presentation, relevant articles, CDC posters, fact sheets and  questions and answers about influenza vaccine effectiveness and safety, and links to other web-based resources.  The toolkit should be available on an HHS website in the near future. 

## HHS Initiative for Influenza Vaccination of Health Care Personnel:  Outreach 

- Potential partners include, but are not limited to:
**American Academy of Family Physicians **
**American Academy of Pediatrics **
**American Association of Homes and Services for the Aging **
**American Association for Respiratory Care**
**American College of Obstetricians and Gynecologists **
**American College of Occupational and Environmental Medicine **
**American College of Physicians **
**American Federation of Labor and Congress of Industrial Organizations**
**American Federation of State, County, and Municipal Employees **
**American Health Care Association **
**American Hospital Association **
**American Medical Association **
**American Nurses Association **
**American Society of Health-System Pharmacists **
**Association for Professionals in Infection Control and Epidemiology, Inc. **
**National Black Nurses Association **
**National Foundation for Infectious Diseases **
**National Hispanic Medical Association **
**National Hispanic Nurses Association **
**National Influenza Vaccine Summit **
**National Medical Association **
**National Medical Association**
**Service Employees International Union **

**HHS will also promote Influenza Vaccination of Health Care Personnel (HCP) nationwide**
**Healthy People 2010 target:  60% of all HHS HCP will be vaccinated annually**
**By 2010**
**HHS plans to partner with many other organizations to promote HCP influenza vaccination **

**Notes:**
The second component of this HHS initiative is outreach to organizations such as the National Influenza Vaccine Summit, and the member organizations you all represent.  We really want to achieve the Healthy People 60% vaccination objective by the year 2010. 

## Influenza

**Highly infectious viral illness**
**3 pandemics in 20th century**
**Estimated 21 million deaths worldwide in pandemic of 1918-1919**
**Virus first isolated in 1933**

## Influenza Pathogenesis

**Respiratory transmission of virus likely major route of transmission**
**Replication in respiratory epithelium with subsequent destruction of cells**
**Viremia rarely documented**
**Viral shedding in respiratory secretions for 1 day before illness and 5-10 days after illness onset**

## Slide 7

**Notes:**

A cough and subsequent spray of respiratory secretions illustrate how influenza is usually spread.

## Impact of Influenza-United States

- 5% to 20% of the population are infected every year.
- Approximately 36,000 annual influenza-associated deaths on average
- Persons 65 years of age and older account for more than 90% of deaths
- Higher mortality during seasons when influenza type A (H3N2) viruses predominate

## Highest rates of complications and hospitalization occur among young children and person 65 years and older

Average of more than 200,000 influenza-related excess hospitalizations annually

57% of hospitalizations among persons younger than 65 years of age

Greater number of hospitalizations during type A (H3N2) epidemics

- Average of more than 200,000 influenza-related excess hospitalizations annually
- 57% of hospitalizations among persons younger than 65 years of age
- Greater number of hospitalizations during type A (H3N2) epidemics

**Impact of Influenza-United States**

## Impact of Influenza in HCP

- In one randomized controlled trial of influenza vaccination of HCP, between 7.1% and 26% of unvaccinated HCP had documented serologic evidence of influenza infection in any one year.
- Of these, 42% could not recall having  a febrile respiratory illness1

- 1Wilde et al., JAMA 1999;281:908—13

**Notes:**
Influenza infections vary widely in their incidence from year to year.  In this study conducted over 3 years, the incidence ranged between 7.1% and 26% in unvaccinated health care personnel, while only 0 to 3.9% in vaccinated personnel.  Of the unvaccinated persons, 42% could not recall having an influenza like illness with fever and respiratory symptoms, and 71% of those infected persons went to work, even some of those who were ill.

## Impact of Influenza Vaccination of HCP on patients

- Over 12 years in one hospital, vaccination coverage increased from 4% to 67%
- Laboratory-confirmed influenza cases among HCP decreased from 42% to 9%
- Nosocomial cases among hospitalized patients decreased 32% to 0 (p<0.0001)1
- Two randomized controlled trials evaluated impact of HCP influenza vaccination on residents in nursing homes2,3
- They estimated > 40% decrease in overall mortality among residents in the setting of high employee vaccination levels, regardless of patient vaccination levels.

- 1Salgado et al., Inf Cont Hosp Epi 2004;25:923-8
- 2Carman et al., Lancet 2000;355(9198): 93--7
- 3Potter, et al., J Infect Dis 1997;175:1--6

**Notes:**
Influenza vaccine will decrease nosocomial infections, or transmission of influenza infection from health care personnel to patients.  One hospital demonstrated a 100% drop in nosocomial influenza infections after increasing health care personnel vaccination rates to 67%.  Two nursing home studies demonstrated over 40% drops in overall mortality among residents if health care personnel vaccination rates were in the range of 50% or higher.

## Influenza Vaccines

- Inactivated subunit (TIV)
- intramuscular
- trivalent
- split virus and subunit types
- Yearly vaccination
- Live attenuated vaccine (LAIV)
- intranasal
- Trivalent
- Yearly vaccination

**Notes:**
There are two types of influenza vaccines:  the inactivated, injectable vaccine, or “flu shot,” and the live, attnuated, or weakened, nasal spray vaccine.  Both contain three types of influenza viruses, and both must be given each year to assure optimal protection.

## Inactivated Influenza Vaccine Effectiveness in Adults <65 years

- 80% (95% CI 56% to 91%) efficacious  when  vaccine matched  circulating strain
- 50% (95% CI 27% to 65%) when not well matched** **
- Jefferson, et al.  Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001269.** **

**Notes:**
The inactivated vaccine has been demonstrated to be about 80% effective in preventing influenza infection when the vaccine viruses are well matched to the wild viruses.  Even when the vaccine strains are not well matched, this study estimated the effectiveness was about 50% in preventing influenza.  So one usually gets measurable benefit from the vaccine.

## LAIV Effectiveness in Healthy Adults

**LAIV Effectiveness in Healthy Adults**

- Randomized, double-blind, placebo-controlled challenge study
- 92 healthy adults (LAIV, n = 29; placebo, n = 31; inactivated influenza vaccine, n = 32) aged 18--41 years ne (Treanor et al., Vaccine 1999;18:899--906.)
- Overall efficacy of LAIV and inactivated influenza vaccine in preventing laboratory-documented influenza 85% LAIV and 71% TIV
- Nichol et al., JAMA 1999;282:137—44, study in 1997-98 with suboptimal vaccine-wild virus match; no virologic-proven outcomes
** **24% fewer febrile upper respiratory illness episodes (URI)
- 27% fewer lost work days due to febrile URI
- 41%-45% fewer days of antibiotic use

**Notes:**
The weakened live virus nasal spray vaccine is similarly effective when it was compared in a study to the flu shot, 85% versus 71%.  Studies often look at non-specific illness outcomes, because it is easier and cheaper to study them, than also doing virus cultures on all the study subjects.  Such studies will notably underestimate the vaccine’s effectiveness, because many other viruses, and bacteria, cause illnesses that may act like influenza infection.  When the live vaccine studied in preventing non-specific illness outcomes during influenza seasons, it, like the inactivated vaccine, was significantly effective in preventing upper respiratory illness of any cause, employee absenteeism, and antibiotic use.

## Inactivated Influenza Vaccine Adverse Reactions

**	**Local reactions		15%-20%
- 	Fever, malaise		not common
- 	Allergic reactions		rare
- 	(Anaphylaxis			<1 in 1 million)
- 	Neurological			rare reactions
- 	(Guillain-Barre Syndrome	1 in 1 million)

**Notes:**
The inactivated vaccine is safe, with the most common adverse event being local pain and redness at the site of injection.  Fever and malaise occur occasionally, but not with respiratory symptoms:  you cannot get flu from the flu shot!  Serious allergic reactions such as anaphylaxis are very rare, as is the paralytic illness Guillain Barre syndrome.   The latter has been not been clearly associated with influenza vaccine since 1994.

## Live Attenuated Influenza VaccineAdverse Reactions in Adults

- 18-49 years adults in one clinical trial, signs and symptoms reported more frequently among LAIV recipients (n = 2,548) than placebo recipients (n = 1,290) within 7 days after each dose included
- cough (14% and 11%, respectively)
- runny nose (45% and 27%, respectively)
- sore throat (28% and 17%, respectively)
- chills (9% and 6%, respectively)
- tiredness/weakness (26% and 22%, respectively) ** **

**Belshe RB et al. Clin Infect Dis 2004;39:920--7.**** **

**Notes:**
The weakend live nasal spray vaccine is more likely to cause mile upper respiratory symptoms like runny nose and sore throat than placebo, in as many as 45% of adults, but not more likely to cause fever, chills, or weakness.  Again, you cannot get the flu from this vaccine either.  

## Slide 17

## Influenza Vaccination of Health-care Personnel

- Only 45.3 percent of U.S. health-care personnel  were vaccinated in 2007

***MMWR***** 2006;55 (RR-2). February 24, 2006.**

## Reasons for Accepting Vaccination Among Health-care Personnel

| Reason | Physician
% | Nurse
% | Technician 
or Aide % | Admin. Worker % | Medical Student % |
| --- | --- | --- | --- | --- | --- |
| Fear of getting influenza | 77 | 77 | 60 | 71 | 75 |
| Fear of transmission to patients | 78 | 59 | 60 | 36 | 64 |
| Vaccine is safe | 77 | 56 | 42 | 38 | 63 |
| Vaccine is effective | 70 | 55 | 47 | 36 | 59 |
| Vaccine was free | 44 | 54 | 49 | 62 | 76 |
| Close contact with high risk person at home | 45 | 56 | 42 | 43 | 9 |
| Convenient | 28 | 38 | 44 | 45 | 53 |

- Christini AB, et al. Infect Control Hosp Epidemiol 2007;28:171-7

**Notes:**
The major reasons for accepting influenza vaccine among health care personnel are the knowledge that the vaccines are safe, effective, and prevent transmission of influenza to patients.

## Reasons for Rejecting Vaccination Among Health-care Personnel

| Reason | Physician
% | Nurse
% | Technician 
or Aide % | Admin. Worker % | Medical Student % | Other 
% |
| --- | --- | --- | --- | --- | --- | --- |
| Vaccine shortage | 57 | 40 | 58 | 53 | 34 | 48 |
| Concern about side effects | 17 | 34 | 36 | 25 | 23 | 28 |
| Never get influenza | 14 | 25 | 27 | 18 | 23 | 22 |
| Inconvenience* | 26 | 9 | 4 | 7 | 34 | 13 |
| Forgot | 18 | 8 | 5 | 2 | 11 | 8 |

- Christini AB, et al. Infect Control Hosp Epidemiol 2007;28:171-7

- *Vaccine needs to be made available during all employment shifts.

**Notes:**
Major reasons in this study for not accepting the vaccine were concerns about adverse events and lack of conveniently available vaccine.  Other studies have suggested concerns about the vaccine’s effectiveness, and believing health care personnel are generally healthy, are also reasons for non-vaccination.

## Health Care Worker Groups

- Qualitative Assessment of Factors Influencing Immunization of Health Care Workers, CDC, unpublished data
- Individual in-depth interview or focus group at hospitals in 4 cities (NYC, Hollywood (FL), Scottsdale (AZ), San Francisco, August 2007
- Results
- Professional schools were reported as a driver of vaccination
- Believe vaccines are a mechanism to protect themselves from patients, rather than as a means to protect patients
- Clinical workers demonstrated limited or inaccurate knowledge of infectious diseases and their routes of transmission
- Resistance to seasonal influenza vaccination was characterized by:
- Perceptions of limited applicability to themselves
- Perceptions of minimal consequences from contracting flu
- Pronounced lack of trust in the vaccine

**Notes:**
CDC did a qualitative assessment of health care personnel factors influencing their immunization in 2007 in 4 cities.  They found ...

## Literature reviewHofman F, Ferracin C, Marsh G, Dumas R. Infection 2005;34:142-147

- Literature review of 32 studies performed 1985-2002
- US, Canada, Europe
- Vaccination rates 2.1% - 82%
- Ideas encouraging influenza vaccination
- To protect oneself (33-93%) - strongest motivation
- To protect patients (2-98%) -secondary motivation
- Free and convenient (11-58%)
- Being previously vaccinated
- Following the example set by peers

**Notes:**
A recent literature review found widely varying rates of vaccination in the U.S., Canada, and Europe, with similar reasons to what we saw earlier as motivators for vaccination, with the addition of protecting oneself, and following peer example.

## Literature reviewHofman F, Ferracin C, Marsh G, Dumas R. Infection 2005;34:142-147

- Ideas preventing influenza vaccination
- Fear of adverse events (8-54%)
- Misconception that vaccination can cause influenza (10-45%)
- Not at risk (6-58%)
- Times/locations of vaccination were unsuitable (6-59%)
- Doubt that influenza is a serious disease (2-32%)
- Lack of vaccine efficacy (3-32%) - except physicians
- Fear of injections (4-26%)
- 2 main barriers:
- Misperception of influenza, its risks, the role of HCW in its transmission to patients, and the importance and risks of vaccination
- Lack of (or perceived lack of ) conveniently available vaccine

**Notes:**
(Read the slide points)

## Common Themes

- Reasons for accepting influenza vaccination
- Protect self
- Protect patients
- Convenience
- Peer influence
- Prior experience

- Reasons for rejecting influenza vaccination
- Concerns about vaccine safety or efficacy
- Not at risk (healthy immune system)
- Lack of understanding of transmission of influenza
- Fear of needles
- Not convenient

**Notes:**
So in summary common themes for accepting the vaccine are...

Common themes for rejecting the vaccine include ...

## Notable Differences

- Differences in motivators, barriers and beliefs by
- Category of healthcare worker
- Type of institution
- Age
- Level of knowledge about influenza and vaccine
- Level of trust

**Notes:**
These studies did identify variations in motivators, barriers and beliefs by several variables, including ...

This finding means we have to target our vaccination approach to each audience.

## Strategies for Improving HCP Vaccination Rates

- Successful HCP vaccination programs are multifaceted and combine:
- Education campaigns
- Role models
- Improved access
- Measurement and feedback
- Legislation and regulation
- Task Force on Community Preventive Services currently conducting a systematic review of influenza worksite vaccination** **

**Notes:**
Successful strategies include ...  Combinations of strategies work best.  

CDC’s Task Force on Community Preventive Services is currently reviewing factors influencing successful influenza workplace vaccination.

## Month of Peak Influenza Activity United States, 1976-2006

**13%**

**19%**

**45%**

**13%**

**3%**

**3%**

***MMWR***** 2007;55(RR-6):5**

**There is usually ample time to vaccinate HCP**
**before influenza occurs!**

**Notes:**
It is important to remember that influenza vaccination campaigns can begin as early as September when vaccine is usually available, and can extend into the winter, because influenza activity does not usually peak in the United States until February or later.

Month of Peak Influenza Activity, United States, 1976-2006
December, 13 percent
January, 19 percent
February, 45 percent
March, 13 percent
April, 3 percent
May, 3 percent

Source: MMWR 2007;55 (RR-6):5

- American College of Physicians (ACP)3
- October 2007 - Recommendation that annual influenza vaccine should be required for every health care worker with direct patient care activities.
- Infectious Diseases Society of America  (IDSA)2
- January 2007- Recommendation that U.S. adopt policy to include mandatory annual influenza vaccination among healthcare workers
- Joint Commission on Accreditation of Healthcare Organizations (JCAHO)1
- New standard, effective 1/1/07:  Influenza immunization offered to staff and licensed independent practitioners.
- National Foundation for Infectious Diseases (NFID)4
- Call to Action recommendations and Best Practices for immunizing health care personnel against influenza

**1**_[http://www.jcrinc.com/26813/newsletters/12882/](http://www.jcrinc.com/26813/newsletters/12882/)__, accessed 11/11/07;                   _**2****Pandemic and Seasonal Influenza Principles for U.S. Action, January 2007;       ****3**_[http://www.acponline.org/college/pressroom/hcw.htm](http://www.acponline.org/college/pressroom/hcw.htm)__, accessed 11/13/07;_
**4****http://www.nfid.org, accessed 05/15/08.**

**Support from Professional Groups**

**Notes:**
A number of professional groups have also support strategies to improve HCP vaccination rates.
For example, the ACP made a recommendation in Oct 2007 that . . . 

IDSA’s Pandemic and Seasonal Influenza Principles for the US, published in January 2007, include a recommendation that . . .

JCAHO’s infection control standard, which became effective 1/1/07 is a requirement for accreditation.  This standard includes elements of performance:   
- Annual influenza vaccination program that includes at least staff and licensed independent practitioners. 
- Access to influenza vaccination on-site.
- Educate staff and licensed independent practitioners about the following: 
Flu vaccination 
Non-vaccine control measures (such as the use of appropriate precautions) 
The diagnosis, transmission, and potential impact of influenza

- Evaluate annually vaccination rates and reasons for non-participation in the organization’s immunization program, and  
- Implement enhancements to the program to increase participation. 

Finally, the National Foundation for Infectious Diseases has had a Call to Action program for several years, urging influenza vaccination of health care personnel, which they recently updated, and have added a list of best practices for such vaccination programs.