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If hand hygiene compliance is one of the toughest challenges a hospital faces, surely healthcare worker (HCW) vaccination isn’t too far behind on infection preventionists’ lists of priorities. Influenza immunization rates among HCWs remain low, with only 36 percent to 40 percent of them reporting influenza vaccination each year. These HCWs have no doubt heard the statistic from the Centers for Disease Control and Prevention (CDC) that seasonal influenza outbreaks result in as many as 36,000 deaths and more than 200,000 hospitalizations in the United States annually. Thanks to new CDC guidelines this year, more people are recommended for influenza vaccination than ever before — nearly 250 million Americans, so it’s a tall order both in and out of the hospital environment for HCWs and patients.
One immunization expert who has been watching vaccination trends says he is a bit maudlin over the slow progress being made. “Frankly I’m depressed, because we appear over the past two or three seasons to be stuck where we are and seeing no major improvement in vaccination of HCWs,” says William Schaffner, MD, professor and chairman of the Department of Preventive Medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville, Tenn. “Having said that, and looking at the national data, some institutions have gotten the message, have accepted responsibility, and have energized all of their stakeholders about the importance of immunization. Some institutions have shown substantial progress from one year to the next, increasing their influenza immunization rates among HCWs by 20 percent or more.”
Schaffner explains that the key to boosting HCW immunization rates lies in implementing a number of evidence-driven interventions instead of cherry-picking among what he calls a “menu” of flu prevention strategies. “It takes a lot of work and there’s no single thing you can do to enhance immunization rates; you must do a number of things,” Schaffner emphasizes. “If you omit one or two critical items from the menu, you can make marginal differences but you’re not likely to achieve large success.”
At the top of the menu is buy-in from the healthcare institution’s top leadership, Schaffner says, explaining, “The single most important thing is convincing the most senior leadership in the institution that HCW immunization is important and to expound its importance in every possible venue. They must let everyone know that influenza immunization is an expectation of the institution and that it is part of our professional and ethical responsibility to our patients. We need our institutional leaders to embrace HCW immunization and ensure it is accessible and convenient to all personnel.”
Individuals in the executive suite can serve as role models, says Schaffner, who writes, “Healthcare professionals should view annual influenza vaccine as a professional responsibility for many reasons: it make us positive role models for our patients, it minimizes the likelihood that we will get influenza and be unable to work at a time when the healthcare system needs us most, and it will help us avoid doing harm by infecting patients in our care.”1
Leadership on immunization issues must also be demonstrated by professional societies and organizations, Schaffner says. “The National Foundation for Infectious Diseases (NFID) gathered together a number of organizations to discuss and commit to HCW immunization; that went swimmingly and about 20 groups signed up. We now need these groups to embrace the issue and integrate it into their own programs and activities. So many HCWs look to their professional societies for guidance and if those groups would say explicitly that they expect every member to become immunized and do everything they can to ensure everyone around them is immunized, we could gain important ground. Healthcare institutions must, over time, create a culture where annual influenza immunization of HCWs is an expectation. In order to establish that climate we need the active endorsement and participation of all professional societies because they set the tone. For example, I haven’t seen the American College of Surgeons tell every surgeon they must be vaccinated. Groups can have good hearts and endorse vaccination, but they also need to do something about it. They have accomplished some things around the edges of the issue, but I have not seen evidence that every autumn, these societies are sending the immunization message.”
Another critical item on Schaffner’s menu is taking advantage of every vaccination opportunity. Schaffner writes, “Influenza immunization remains the best defense against the morbidity and mortality associated with influenza infection. National influenza immunization guidelines are in place and are updated annually to identify the groups of individuals that should be vaccinated each year and to provide counsel on how and when vaccine should be administered. Despite this specific guidance to clinicians, community immunizers, and public health workers, there is broad-based evidence of influenza vaccine underutilization in all groups for whom vaccination is warranted, resulting in potentially preventable illness and complications of influenza (pneumonia, hospitalization, and death). One of the contributions to immunization rates that fall far below target levels is a sizable number of missed opportunities throughout the vaccination season (i.e., healthcare visits during which at-risk patients are not vaccinated).”1
Poland2 emphasizes the importance of immunization to be offered to HCWs not just in the fall, but from October through January and beyond, a recommendation from the CDC. “What we are really talking about is a paradigm shift,” says Schaffner. “As the number of people who need to get vaccinated has been expanded by public health officials, so has the time-frame for vaccination. Vaccines given later in the year or even into the New Year are still beneficial in helping people avoid this serious illness.”
Schaffner writes, “The CDC and other health experts have slightly differing definitions of the influenza vaccination season. Although administration of influenza vaccine in October and November is traditional, it has become clear that full implementation of CDC recommendations cannot be accomplished if vaccination occurs only in the fall, in advance of the influenza season. The CDC and others advocate broadening the influenza vaccination season, such that patients are immunized even after influenza activity has begun in a community.”1
Based on CDC recommendations, influenza disease season is defined as October through May, and the influenza vaccination season as October into January and beyond. “This shift in the vaccination timing paradigm requests all healthcare professionals to recognize the value and medical need of vaccines given throughout the season and to vaccinate at-risk patients at every opportunity,” Schaffner writes.1
In February, the CDC expanded its recommendations for annual influenza immunization to include all children 6 months through 18 years of age. The new recommendation is to take effect as soon as feasible, but no later than the 2009-2010 influenza season. The change will add about 30 million children to the total number of people for whom CDC recommends annual influenza vaccination. Schaffner writes, “It is abundantly clear that we cannot vaccinate everyone in a two- to three-month vaccination window. Since influenza usually peaks around February in the U.S., vaccination given in December and later continues to be medically relevant.”1
Poland2 says that healthcare providers are missing important opportunities to vaccinate people during office visits. Based on insurance claims filed by 240,000 physicians from 2004 to 2007, the researchers found that 25 million people at high risk for complications from influenza visited doctors an average of 2.2 times each year between November and February, the usual peak of influenza season, but did not get vaccinated. The researchers urge stepped-up efforts by healthcare providers to take advantage of ongoing access to patients and vaccinate them starting when they make visits during the early fall when vaccine becomes available, and continuing throughout the influenza season.
“Occasionally you have an early season, but most flu occurs in January and February,” Schaffner says. “You can have a flu vaccination campaign in October, but why not keep vaccinating in November, December and January? Some occupational health services want to get in, get done and get out, and we can’t convince them to extend their services through hundreds of other routine interactions with HCWs. In a routine examination they can look at a banged-up elbow and say, ‘By the way, did you get your flu vaccine?’ But they don’t do that. That’s how you can pick up more people along the way, and they will likely be at the front of the vaccination line next year.”
Breaking the barriers to HCW immunization and making influenza vaccination easy and convenient is one of the biggest challenges infection preventionists may face. Schaffner points to the continued misinformation about influenza vaccination that circulates among HCWs.
“There is the enduring belief that the influenza vaccine causes the flu, and this is particularly embedded among nurses,” he says. “That’s unfortunate, because if nurses carry this notion, they are not going to be advocates to get their patients vaccinated. We do realize the influenza vaccine is good but it is not perfect; we know it does not work optimally in certain older or immunocompromised individuals, and there’s not always a perfect match between the influenza vaccine and the circulating strains. Even if it’s not a perfect match, there is partial protection, which is better than no protection at all. Confidence in the vaccine is lacking in physicians as well; there are sophisticated physicians who are very skeptical about the effectiveness of the influenza vaccine and are not behind our institutional flu campaign. They are not barriers to the process, but they won’t be advocates. They’re not infectious disease specialists and they have not studied all of the data, but they know it’s not the greatest vaccine.”
Schaffner continues, “We have senior physicians at our medical center who decline to get vaccinated, which is common among people who don’t realize or accept the fact that they can be robust and still be infected with the influenza virus. They have few, if any, symptoms, but they can spread the virus to their patients. People will say, ‘If I get sick I will stay home,’ but what they fail to understand is the day before they are sick they are already excreting virus, covering their patients with influenza virus. When we bring that to their attention, I can almost see the light bulb go on over people’s heads. That’s a critical piece of information most folks don’t have.”
Johnson3 endeavored to understand why adults do not receive recommended immunizations, and conducted surveys of 2,000 adult consumers and 200 healthcare professionals in the United States. The researchers discovered the most consistent reason for not receiving a vaccine was the belief that a healthy person does not need it (60 percent of respondents). Concern about side effects was cited by 43 percent of consumers as a reason for avoiding influenza immunization. Healthcare professionals were presented reasons why patients might not receive tetanus, influenza, and pneumococcal immunizations; according to healthcare providers, failure of patients to come for regular well-care visits and lack of an effective reminder system were among the more common reasons that adults do not receive recommended immunizations. Healthcare providers also indicated that patients’ dislike of needles, fear of adverse effects, and lack of knowledge about disease prevention were frequently responsible for missed immunizations.
Stinchfield4 says healthcare providers can overcome HCW immunization barriers by establishing weekend, evening or parallel track daytime “influenza only” vaccination clinics; issuing standing orders that allow nurses and other healthcare providers to vaccinate without direct doctor supervision; and increased reminder and recall efforts.
Earlier this year, the CDC introduced its enhanced recommendations designed to increase influenza vaccination coverage among HCWs. The new recommendations provide strategies to make vaccine more accessible to HCWs and to help facilities better determine coverage rates and the reasons their staff have for not getting vaccinated.
The guidance, drafted by CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP), recommends that:
• Facilities offer influenza vaccine annually to all eligible personnel.
• Vaccine be offered at the workplace, during all shifts and at no cost to employees.
• Hospitals use strategies proven to improve vaccination coverage, including: education to combat fears and misconceptions about influenza and influenza vaccines, use of reminders to staff, having leadership set an example by getting vaccinated.
• Facilities obtain a signed form from staff who decline vaccination for reasons other than medical. This tool is designed to help facilities better monitor who is offered vaccine, employee concerns and barriers to vaccination so appropriate strategies can be designed to improve vaccination coverage.
The recommendations ask facilities to monitor influenza vaccination coverage at regular intervals during influenza season and provide feedback of ward-, unit-, and specialty-specific coverage to staff and administration. Influenza vaccination coverage should be one measure of the quality of an institution’s patient safety programs. The guidelines also reiterate an earlier HICPAC recommendation that influenza vaccination coverage of HCWs be used as a healthcare quality measure in states that mandate public reporting of healthcare-associated infections.
“We want healthcare facilities to be even more aggressive in protecting their staff and patients from influenza,” said Denise Cardo, MD, chief of CDC’s Division of Healthcare Quality Promotion in a press release. “Improving influenza vaccine coverage among healthcare personnel is vital to patient safety and protects staff as well.”
The Department of Veterans Affairs (VA) offers the following suggestions on how to boost HCW vaccination rates:5
• Send a letter, postcard or email to employees prior to the start of the vaccine season reminding them of the importance of vaccination, where and when they will be able to get the flu vaccine.
• Write something about the flu in the employee newsletter or post information on staff bulletin boards and provide fact sheets with pay stubs to dispel misconceptions and increase acceptance.
• Increase the number of sites where the vaccine is given. Use mobile carts to transport to different clinic areas, service meetings, grand rounds or near cafeteria entrances. This approach can minimize inconvenience as well as means to advertise the vaccine availability. Carts should be stocked with vaccine, safety syringes, vaccine information statements, sharps disposal containers, alcohol hand rub, alcohol wipes, adhesive bandages, documentation forms, and injectable epinephrine with orders for administration in the event of an acute hypersensitivity reaction.
• In late November, identify employees not yet vaccinated and remind them by e-mail or a phone call that the flu vaccine is available.
• Give out buttons or stickers to all staff who are vaccinated.
• Hold an influenza vaccination kick-off event with food and freebies.
According to the VA, key elements of a successful staff flu vaccination campaign include:
• informing employees about the availability of the vaccine
• educating employees about its importance
• making the vaccine convenient
• notifying employees regarding the scheduling of administration
• keeping track of who has been vaccinated
1. Schaffner W. Expanding the influenza vaccination season. Am J Med. Vol 121, No 7B. July 2008.
2. Poland GA and Johnson DR. Increasing influenza vaccination rates: The need
to vaccinate throughout the entire influenza season. Am J Med. Vol 121, No 7B. July 2008.
3. Johnson DR, Nichol KL, and Lipczynski K. Barriers to adult immunization. Am J Med. Vol 121, No 7B. July 2008.
4. Stinchfield K. Practice-proven interventions to increase vaccination rates and broaden the immunization season. Am J Med. Vol 121, No 7B. July 2008.
5. Department of Veterans Affairs. http://www.publichealth.va.gov/flu/flu_hcw.htm
National Foundation for Infectious Diseases (NFID). Accessed at: http://www.nfid.org/influenza/health_professionals.html