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

Breaking Down Barriers to Healthcare Worker Immunization

By Kathy Dix

Getting 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 Diseases.

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 education.

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 agrees.

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.

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