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


Breaking Down Barriers to Healthcare Worker Immunization

By Kathy Dix

Gettingimmunized to prevent patients from exposure and to keep yourself well enough totreat them doesnt seem like rocket science. But many infection controlpractitioners have a terrible time convincing their employees to be immunizedfor flu, measles and hepatitis.

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

When the hospital first conceived the idea approximately twoyears ago, no one would sign up to take the vaccine when the state was offeringit, 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 aroundand vaccinate the rest of our employees, then they started to volunteer, andthat was really the only way we could get any response at all.

At the time, the infection control department offerededucation 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. Thisday served as the basis for most of the volunteers.

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

McGough does not anticipate problems if there were to be aninfluenza pandemic, or if a SARS (severe acute respiratory syndrome) vaccinewere to become available. The smallpox vaccine has a bad reputation becauseof all the side effects, and people are afraid of it, not necessarily forthemselves, 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 triedto 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, theresnothing going on and dont need to worry about it?

Breaking Down the Barriers

Many facilities, however, do have a great deal of troublegetting their employees to take an influenza vaccine every year. There areseveral reasons for this, says William Schaffner, MD, professor and chairman ofthe department of preventive medicine at Vanderbilt University Medical Center inNashville, Tenn., and a board member of the National Foundation for InfectiousDiseases.

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

Of course, they have a second, third, or even a fourthreason, he adds. The second reason is that we want them to be healthy whenflu hits, so they can perform their function. The third reason, the traditionalreason, 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 theinformation about who should get flu vaccine, they dont see themselves asover 50, with underlying heart or lung disease; they see themselves as healthyand not needing it. We have not been clear enough in giving them the informationthat this is an issue that in this case transcends their personal health. Inother words, were not so much trying to protect them against developing thecomplications of influenza pneumonia and hospitalization but in thiscase, we want them to be immunized so they dont give flu to the patients.

The fourth reason is to prevent bringing influenza home totheir loved ones. An additional piece of information HCWs probably need: theyoften 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 onlyafter you acquire the influenza virus but for about 24 hours beforeyou become sick, you can transmit the flu virus toothers. So theres no way that the strategy (even if it were real Ill stay home when Im sick and wont hurt the patients) willwork, because you could be infected, feel perfectly well and be handing out flualong with your medicines, says Schaffner.

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

Many institutions bring the flu vaccine right to the worksite. But thats not enough. The last reason is and weve learned thisboth here at Vanderbilt and nationally with focus groups of HCWs there aremany HCWs, and Im afraid more nurses than others, who still believe the mythsabout influenza vaccine.

The thing we still hear is, You know, I think you canget the flu from the flu vaccine, which is, of course, nonsense. There mayhave been instances in the past when people have gotten the influenza vaccineand 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 didntthink we had to give HCWs, but we have to, he observes.

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

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

From an institutional point of view, theres another goodreason for having an effective annual immunization program. There are concernsthat new influenza strains may appear and create pandemic flus. There are alsoconcerns about bioterrorist events. If [institutions] have effective annualinfluenza immunization campaigns, they know how to do it; the machinery is inplace and its like taking the car out and driving it around the block. Notonly do you provide good protection for your workforce and their patients, butyou actually go through the same motions you would go through in the event thatyou had a bio-terrorist or pandemic event.

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

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

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

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

Programs That Work

Childrens Healthcare of Atlanta employees must undergo anextensive (free) health assessment to work at Childrens, which includes a TBtest and a copy of his/her immunization records. Childrens also stronglyencourages its employees to get a flu shot in the fall before the flu seasonbegins. HCWs set up stations at the three main campuses to giveemployees free flu shots. Frequent reminders about the flu shot will appear ininternal communications such as the internal Web site and the newsletter and aresent through e-mail and managerial announcements.

Asked how she convinces her employees to be immunized, JeanRandolph, RN, occupational health manager at the healthcare system, says, Theyrereally good when theyre captive, when they start work with you, and you canget 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 todo it. Once they start working in the new place, theres so much they have tolearn, 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 MMRshot, she sends a letter to the employees home. If the employee does notrespond, she phones the employees manager and asks when theyre workingnext, then informs the manager that the employee cannot begin work that dayuntil after receiving the necessary immunizations. Randolph emphasizes the one-on-one contact with thesupervisor, but points out that it must be within a day or two of the employeesnext shift; otherwise, the manager is likely to forget.

Because were a childrens healthcare system, itsreally important that people are immunized for things like measles, mumps,rubella and chicken pox, she observes. Thats probably more important tous than anything else, primarily because it reduces the exposure toimmune-suppressed children. Our employees understand that, and I dont mean tosound like theyre running away from their shots; remembering to go get a shotin employee health just doesnt fit into the day. The employee will oftenprotest that there just isnt time, but Randolph promises to see the employeeimmediately, and does so. The hospital sends a reminder letter to the employeeshome when its time to get an updated shot; many will show up with the letterin 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 goto every building that houses a Childrens Healthcare employee in the month ofOctober. In the hospitals, we have a cart set up with a big sign that says, FreeCandy, 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 ofcandy. I dont mind buying extra candy; thats OK with me.

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

Three infection control nurses at Kennedy Health System inCherry Hill, N.J. also have an effective program for promoting immunization.Charline Cearfoss, RN, CIC, Kathy Hosmer, RN, and Eleanor Delaney, RN, CIC, whowork 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 copyof the results of that test, and a form that tells them whether or not theyreimmune, and we get copies in their charts. They get a note saying they need tocontact 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 needto stop by, because we require that they that they sign a waiver if theychoose not to be vaccinated. That gives us an opportunity to do additionaleducation.

Delaney interjects, They also need to know that if they areexposed to any of these diseases and if we dont have anything on our recordsindicating they are immune, they will be taken out of work for a period of timewhile were waiting to see if they actually pick up the disease. Its a relieffrom duty.

Barriers to being immunized are several, but the two mainreasons, 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, theyreconvinced 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 weneed to talk about what they think was the case they had before or why they feelthat way, says Cearfoss. Usually, even if you have a mild case, youshould come up immune, but some peoples immunity seems to wane over time. Weget enough patients in the hospital with zoster which is the same virus; its just not contagious by the respiratory tract butcertainly by contact that we like to have our people immunized against it sowe dont have to worry about not having them take care of those patients. Delaney adds, A problem with the chicken pox vaccine isthat theyre afraid of taking it home if they have small children themselves.

There are certain people who may develop a very mild caseas a result of being vaccinated, and if Im not mistaken, its not actuallycommunicable, but its sometimes dif. cult to tell people that and have thembelieve it if theyre symptomatic with even mild side effects, Cearfossagrees.

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

Some vaccinations are brought to the units, she adds. Thatsnot necessarily because of their noncompliance; an example would be in the ORwhere its dif. cult for them to get out because of their schedule. Cearfoss offers employees candy as an incentive; Delaney doesnot. 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 linedup at my door half an hour before I open, looking for it. Theyve discoveredthat they dont have the major side effects, they dont have to worry aboutgetting sick, and theyre not taking anything home to their families, and itmakes a big difference in how they can plan their lives.

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