Infection Control Today - 09/2004: THE WALLS COME TUMBLING DOWN

September 1, 2004

Breaking Down Barriers to Healthcare Worker Immunization

By Kathy Dix

immunized to prevent patients from exposure and to keep yourself well enough to
treat them doesnt seem like rocket science. But many infection control
practitioners have a terrible time convincing their employees to be immunized
for flu, measles and hepatitis.

The infection control department at Overlook Hospital in
Summit, N.J., conducted a smallpox immunization drill at the end of July as a
mock mass immunization for all its healthcare providers. The idea behind the
whole clinic drill is, number one, to see if our plans actually work, and number
two, to be ready for any type of mass vaccination, such as for a pandemic of
influenza this year, or mass antibiotics for anthrax exposure, says Sonja
McGough, manager of infection control at the hospital.

When the hospital first conceived the idea approximately two
years ago, no one would sign up to take the vaccine when the state was offering
it, says McGough. But we found out that if we asked them to be on this
emergency response team that they would take the vaccine first, then turn around
and vaccinate the rest of our employees, then they started to volunteer, and
that was really the only way we could get any response at all.

At the time, the infection control department offered
education on the smallpox vaccine, the disease itself and how it is transmitted,
which did not generate much attendance. But the hospital also has a Mega Day,
one day a month that is devoted entirely to mandatory education and safety. This
day served as the basis for most of the volunteers.

It was a major challenge, and still is, McGough observes. However, I think our staff is
sophisticated enough that they would step up to the plate if we were to have
some major catastrophe.

McGough does not anticipate problems if there were to be an
influenza pandemic, or if a SARS (severe acute respiratory syndrome) vaccine
were to become available. The smallpox vaccine has a bad reputation because
of all the side effects, and people are afraid of it, not necessarily for
themselves, but if they have young children at home, or immuno-suppressed family.
Smallpox got a bad rap, and part of it was probably the way they initially tried
to get people to be vaccinated. There was no emergency, and people were saying,
Why should I risk my life or my familys life, if in fact, theres
nothing going on and dont need to worry about it?

Breaking Down the Barriers

Many facilities, however, do have a great deal of trouble
getting their employees to take an influenza vaccine every year. There are
several reasons for this, says William Schaffner, MD, professor and chairman of
the department of preventive medicine at Vanderbilt University Medical Center in
Nashville, Tenn., and a board member of the National Foundation for Infectious

The first reason is and Im afraid I have to say mea
culpa, because Ive been trying to promote influenza immunization for some time
those of us who have promoted this and made this recommendation have not made
clear to healthcare workers (HCWs) the main reason theyre being asked to be
immunized against influenza. The main reason is patient safety, so they do not
transmit influenza to their patients who are, of course, vulnerable and at risk
of the complications of influenza, Schaffner says.

Of course, they have a second, third, or even a fourth
reason, he adds. The second reason is that we want them to be healthy when
flu hits, so they can perform their function. The third reason, the traditional
reason, the reason they have focused on, is personal health. For the most part,
HCWs are part of the healthy-worker group, so as they have listened to the
information about who should get flu vaccine, they dont see themselves as
over 50, with underlying heart or lung disease; they see themselves as healthy
and not needing it. We have not been clear enough in giving them the information
that this is an issue that in this case transcends their personal health. In
other words, were not so much trying to protect them against developing the
complications of influenza pneumonia and hospitalization but in this
case, we want them to be immunized so they dont give flu to the patients.

The fourth reason is to prevent bringing influenza home to
their loved ones. An additional piece of information HCWs probably need: they
often say, If I get flu, Ill stay home. First of all, they never do
Ive been there myself and second, we have not taught them that not only
after you acquire the influenza virus but for about 24 hours before
you become sick
, you can transmit the flu virus to
others. So theres no way that the strategy (even if it were real
Ill stay home when Im sick and wont hurt the patients) will
work, because you could be infected, feel perfectly well and be handing out flu
along with your medicines, says Schaffner.

Another reason is that some HCWs dont like shots. My
response to that is, Get over it. This is something that has to do with a
professional obligation. Another reason is that theyre so busy, its not
convenient. This is the responsibility of the institution, and if this is indeed
a patient-safety issue, it is an institutional issue, and it is an institutional
responsibility to bring influenza vaccine conveniently to the HCW. If the HCW
has to leave their ward and go two buildings over to the occupational health
service on their own time, thats not going to work. Big surprise.

Many institutions bring the flu vaccine right to the work
site. But thats not enough. The last reason is and weve learned this
both here at Vanderbilt and nationally with focus groups of HCWs there are
many HCWs, and Im afraid more nurses than others, who still believe the myths
about influenza vaccine.

The thing we still hear is, You know, I think you can
get the flu from the flu vaccine, which is, of course, nonsense. There may
have been instances in the past when people have gotten the influenza vaccine
and two days later got a cold, but they would have gotten the cold anyway. Hello
thats not because of the flu shot! Thats also information we didnt
think we had to give HCWs, but we have to, he observes.

A lot of this responsibility comes back to [the NFID]. We
have to make our messages much more clear. Theres also a major institutional
responsibility if this is a patient safety issue, and we believe it is, then
the institution has the responsibility for giving this priority, for the
leadership in the institution to let everyone know theyre behind it, for the
institution to demonstrate or articulate/communicate that this is a professional
responsibility, we have expectations of virtually 100 percent acceptance, and
for the institution to make it convenient and to provide the vaccine. This
removes another barrier: there are some people who are reluctant to pay whatever
it costs.

Schaffner continues, Then the institution of course has to
give this some budget and organize a program to deliver the
vaccine, and it would be useful to audit performance while were doing it, by
occupational site, by ward or clinic, to make sure that you can keep track of
which units seem to have higher immunization rates give them applause
and which units have lower have immunization rates where we have to come back
again and perhaps do a bit more in-service and persuasion.

From an institutional point of view, theres another good
reason for having an effective annual immunization program. There are concerns
that new influenza strains may appear and create pandemic flus. There are also
concerns about bioterrorist events. If [institutions] have effective annual
influenza immunization campaigns, they know how to do it; the machinery is in
place and its like taking the car out and driving it around the block. Not
only do you provide good protection for your workforce and their patients, but
you actually go through the same motions you would go through in the event that
you had a bio-terrorist or pandemic event.

There are two advisory committees to the Centers for Disease
Control and Prevention (CDC) the Advisory Committee on Immunization
Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee
(HICPAC). ACIP has long recommended HCW immunization and has been distressed by
the national average of 38 percent; HICPAC has a comparable recommendation. Whats
in the works right now is both committees have joined to create a restatement of
this, which will have even more energy and force and should be out before the
current influenza vaccination season, Schaffner says.

Schaffner has been most closely involved with the NFID,
however; the organization convened a roundtable meeting in February
with 25 professional organizations, which have all agreed that annual flu
vaccines for HCWs are, professionally and ethically, the correct thing to do.
The NFID then asked these organizations to individually bring this to the
attention of their membership and ask them to immunize themselves and their
employees. Were trying to change the culture, such that this becomes not a
possible thing to do, not something to give consideration, but a routine
professional obligation every autumn, and it is in the interest of patient
safety, Schaffner says.

We all know that influenza vaccine has to be created and
new each year because the flu virus changes, and we all know that introduces a
measure of uncertainty, sometimes the match between the vaccine and the
circulating influenza strain is perfect, and other times not so good. But even
then, there is protection. Its not that theres no protection; its just
that there is less. We recognize that it is an imperfect vaccine. That cannot
permit us to do nothing. I paraphrase the French philosopher Voltaire, who said
waiting for perfection is the greatest enemy of the current good. What we have is a pretty darn good influenza vaccine not
perfect but pretty darn good. We need to use it both to protect our patients by immunizing ourselves and by making sure that
they are immunized. By doing both very efficiently, we will substantially reduce
we cannot expect to eliminate but we will substantially reduce the
serious impact of annual influenza epidemics in this country.

Were trying to inculcate into the minds, the hearts and
the souls of healthcare workers that this is the professionally and ethically
appropriate thing to do. We want them to want to do it and to recognize that
thats the norm, the new professional norm, to get vaccinated every darn year.

Programs That Work

Childrens Healthcare of Atlanta employees must undergo an
extensive (free) health assessment to work at Childrens, which includes a TB
test and a copy of his/her immunization records. Childrens also strongly
encourages its employees to get a flu shot in the fall before the flu season
begins. HCWs set up stations at the three main campuses to give
employees free flu shots. Frequent reminders about the flu shot will appear in
internal communications such as the internal Web site and the newsletter and are
sent through e-mail and managerial announcements.

Asked how she convinces her employees to be immunized, Jean
Randolph, RN, occupational health manager at the healthcare system, says, Theyre
really good when theyre captive, when they start work with you, and you can
get as many immunizations into them as possible on their pre-employment physical.
After that, getting them to come back its not that they dont want to
do it. Once they start working in the new place, theres so much they have to
learn, its just a huge amount of time and energy.

However, Randolph has developed a highly effective strategy;
if an employee needs the third of a series of hepatitis shots, or an updated MMR
shot, she sends a letter to the employees home. If the employee does not
respond, she phones the employees manager and asks when theyre working
next, then informs the manager that the employee cannot begin work that day
until after receiving the necessary immunizations. Randolph emphasizes the one-on-one contact with the
supervisor, but points out that it must be within a day or two of the employees
next shift; otherwise, the manager is likely to forget.

Because were a childrens healthcare system, its
really important that people are immunized for things like measles, mumps,
rubella and chicken pox, she observes. Thats probably more important to
us than anything else, primarily because it reduces the exposure to
immune-suppressed children. Our employees understand that, and I dont mean to
sound like theyre running away from their shots; remembering to go get a shot
in employee health just doesnt fit into the day. The employee will often
protest that there just isnt time, but Randolph promises to see the employee
immediately, and does so. The hospital sends a reminder letter to the employees
home when its time to get an updated shot; many will show up with the letter
in hand.

The flu vaccine is a different animal. We do the best we
can to put carrots out to entice them, she says. We have two hospitals; 20-
something off-site facilities, and an office park with 14 buildings. We go
to every building that houses a Childrens Healthcare employee in the month of
October. In the hospitals, we have a cart set up with a big sign that says, Free
Candy, and in little letters underneath it, it says, With Your Flu Shot.
They can see the candy; candys a real pull. So they mosey on over, ask, Hey,
are you giving that away? Sure, heres your flu shot. Have a piece of
candy. I dont mind buying extra candy; thats OK with me.

Of 5,500 employees, 4,000 of whom are direct patient
caregivers, the health system gave 3,300 flu shots last year. This year, there
are new inducements to be immunized daily raffies with points worth
money, and donated prizes.

Three infection control nurses at Kennedy Health System in
Cherry Hill, N.J. also have an effective program for promoting immunization.
Charline Cearfoss, RN, CIC, Kathy Hosmer, RN, and Eleanor Delaney, RN, CIC, who
work for Cherry Hill, Stratford and Washington Township hospitals, respectively,
believe in constant education about the need to be immunized.

They get tested when . rst hired for immunity to rubella,
rubiola, and varicella, and also hepatitis, says Cearfoss. They get a copy
of the results of that test, and a form that tells them whether or not theyre
immune, and we get copies in their charts. They get a note saying they need to
contact infection control if theyre interested in being vaccinated.

If we dont hear from them, we send them another note,
saying, You are not immune to (whichever of the diseases it is) and you need
to stop by, because we require that they that they sign a waiver if they
choose not to be vaccinated. That gives us an opportunity to do additional

Delaney interjects, They also need to know that if they are
exposed to any of these diseases and if we dont have anything on our records
indicating they are immune, they will be taken out of work for a period of time
while were waiting to see if they actually pick up the disease. Its a relief
from duty.

Barriers to being immunized are several, but the two main
reasons, Hosmer says, are that They just dont have the time to come off [the
floor], or a lot of them just dont want the vaccine.

Many times, particularly with varicella, theyre
convinced that theyve had chicken pox in the past and they dont need it,
even if theyre coming up negative. There may be some validity to that, but we
need to talk about what they think was the case they had before or why they feel
that way, says Cearfoss. Usually, even if you have a mild case, you
should come up immune, but some peoples immunity seems to wane over time. We
get enough patients in the hospital with zoster which is the same virus; its just not contagious by the respiratory tract but
certainly by contact that we like to have our people immunized against it so
we dont have to worry about not having them take care of those patients. Delaney adds, A problem with the chicken pox vaccine is
that theyre afraid of taking it home if they have small children themselves.

There are certain people who may develop a very mild case
as a result of being vaccinated, and if Im not mistaken, its not actually
communicable, but its sometimes dif. cult to tell people that and have them
believe it if theyre symptomatic with even mild side effects, Cearfoss

Recently, a HCW didnt want to get the chicken pox
vaccine because she had a young child, so I told her, when her child gets the
vaccine, let her get it at the same time. She called me yesterday and set them
both up for August, Delaney says.

Some vaccinations are brought to the units, she adds. Thats
not necessarily because of their noncompliance; an example would be in the OR
where its dif. cult for them to get out because of their schedule. Cearfoss offers employees candy as an incentive; Delaney does
not. Hosmer, however, says, Its amazing; candy does work!
They say, I came for the chocolate. As far as large departmental rewards,
we havent done that. Were a one-man show at each hospital, so its dif.
cult for us to get a lot of things coordinated. We do a lot of things manually.
Reward has been dif. cult.

But education, for the flu virus at least, has been effective.
Cearfoss says, I have certain people, if they know the day, who will be lined
up at my door half an hour before I open, looking for it. Theyve discovered
that they dont have the major side effects, they dont have to worry about
getting sick, and theyre not taking anything home to their families, and it
makes a big difference in how they can plan their lives.