7 th June 2011 Promoting Flu vaccination for

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7 th June 2011 Promoting Flu vaccination for Health Care Workers Insert name of

7 th June 2011 Promoting Flu vaccination for Health Care Workers Insert name of presentation on Master Slide Dr Brendan W Mason Regional Epidemiologist

Why bother? • Trivalent seasonal influenza vaccine should be offered to: – Health care

Why bother? • Trivalent seasonal influenza vaccine should be offered to: – Health care staff directly involved in the care of patients. – Others involved directly in delivering health care such that they and vulnerable patients are at increased risk of exposure to seasonal influenza. JANUARY 2011 UPDATE http: //www. dh. gov. uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_123590. pd UK Policy

Why bother? • “Getting employees vaccinated against the flu should be a corporate health

Why bother? • “Getting employees vaccinated against the flu should be a corporate health priority as low uptake levels may put the people being cared for at risk. ” • “NHS organisations should proactively encourage those directly involved in patient care to be vaccinated. ” LETTER FROM HEALTH MINISTER TO CHAIRS NHS HEALTH BOARDS 1 st JULY 2010 http: //wales. gov. uk/docs/dhss/publications/100713 ml 02510 en. pdf Welsh Policy Copyright Leah Millinship

Why bother? 1. Prevent transmission of influenza from HCWs to patients – Patients at

Why bother? 1. Prevent transmission of influenza from HCWs to patients – Patients at increased risk of acquiring influenza – Patients at increased risk of death or serious illness from influenza 2. Avoid disruption to services that provide patient care 3. Protect HCWs from influenza 4. Protect families HCWs from influenza Intended outcome of policy

Why bother? • How big is the problem? • How effective is the intervention?

Why bother? • How big is the problem? • How effective is the intervention? Health impact

Protecting patients: systematic review effectiveness • Influenza vaccination for HCWs who work with the

Protecting patients: systematic review effectiveness • Influenza vaccination for HCWs who work with the elderly: – 4 cluster randomised controlled trials (n = 8468) – over 60 s in long term care facilities • Statistically significant reductions: – Influenza-like illness (ILI); GP consultations for ILI; all-cause mortality. • Non significant reductions: – Laboratory confirmed influenza; pneumonia; deaths from pneumonia. Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. Cochrane. Database of Systematic Reviews 2010, Issue 2. Art. No. : CD 005187. DOI: 10. 1002/14651858. CD 005187. pub 3. Evidence base

Protecting patients: systematic review effectiveness Outcome Number studies Number patients Relative 95% CI Risk

Protecting patients: systematic review effectiveness Outcome Number studies Number patients Relative 95% CI Risk Influenza-like illness 3 7031 0. 71 0. 55 -0. 90 Confirmed Influenza 2 752 0. 86 0. 44 -1. 68 GP consultations ILI 1 2572 0. 48 0. 38 -0. 61 Pneumonia 1 1059 0. 70 0. 41 -1. 20 Death from pneumonia 2 4459 0. 82 0. 45 -1. 49 Death from all causes 4 8468 0. 66 0. 55 -0. 79 Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. Cochrane. Database of Systematic Reviews 2010, Issue 2. Art. No. : CD 005187. DOI: 10. 1002/14651858. CD 005187. pub 3. Evidence base

Protecting patients: systematic review effectiveness Outcome Number studies Number patients Effect Size 95% CI

Protecting patients: systematic review effectiveness Outcome Number studies Number patients Effect Size 95% CI Influenza-like illness 3 7031 0. 71 0. 55 -0. 90 Confirmed Influenza 2 752 0. 86 0. 44 -1. 68 GP consultations ILI 1 2572 0. 48 0. 38 -0. 61 Pneumonia 1 1059 0. 70 0. 41 -1. 20 Death from pneumonia 2 4459 0. 82 0. 45 -1. 49 Death from all causes 4 8468 0. 66 0. 55 -0. 79 • All cause mortality in patients in units where HCWs offered flu vaccine estimated to be 66% of level in units where HCWs not immunised = One third reduction in deaths in patients in units where HCWs offered immunisation • 95 % confidence interval estimate reduction in mortality 21% to 45% Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. Cochrane. Database of Systematic Reviews 2010, Issue 2. Art. No. : CD 005187. DOI: 10. 1002/14651858. CD 005187. pub 3

Protecting patients: systematic review effectiveness Thomas RE et al. Influenza vaccination for healthcare workers

Protecting patients: systematic review effectiveness Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. Cochrane. Database of Systematic Reviews 2010, Issue 2. Art. No. : CD 005187. DOI: 10. 1002/14651858. CD 005187. pub 3

Protecting patients: systematic review effectiveness • Over a 4 -5 month period of high

Protecting patients: systematic review effectiveness • Over a 4 -5 month period of high influenza activity: – 13% (555/4258) patients died in units where HCW not immunised – 9% (381/4210) patients died in units where HCW offered immunised • Absolute reduction in all cause mortality 4% • Highly statistically significant p=0. 00001 Thomas RE et al. Influenza vaccination for healthcare workers who work with the elderly. Cochrane. Database of Systematic Reviews 2010, Issue 2. Art. No. : CD 005187. DOI: 10. 1002/14651858. CD 005187. pub 3

Protecting patients: economic evaluation • Most likely scenario – Vaccination HCW was cost saving

Protecting patients: economic evaluation • Most likely scenario – Vaccination HCW was cost saving – Saving of £ 12/vaccinee • Most pessimistic scenario – Cost £ 405/life-year gained Burls A et al. Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006; 24: 4212– 21. Evidence base

Protecting patients: economic evaluation • Most likely scenario – Typical Welsh Health Board saving

Protecting patients: economic evaluation • Most likely scenario – Typical Welsh Health Board saving £ 175, 000/year • Most pessimistic scenario – Cost £ 405/life-year gained – Cf. NICE cost effectiveness threshold £ 30 000 per quality adjusted life year (QALY) gained • Effective implementation should be a priority. Burls A et al. Vaccinating healthcare workers against influenza to protect the vulnerable—Is it a good use of healthcare resources? A systematic review of the evidence and an economic evaluation. Vaccine 2006; 24: 4212– 21. Evidence base

Protecting HCWs: systematic review effectiveness • Influenza vaccines in healthy individuals aged 16 to

Protecting HCWs: systematic review effectiveness • Influenza vaccines in healthy individuals aged 16 to 65 years: – 40 randomised controlled trials (n = 70, 000) • Statistically significant reductions: – Influenza-like illness (ILI); Laboratory confirmed influenza; working days lost; antibiotics prescribed. • Non significant reductions: – GP consultations; pneumonia; hospital admission. Jefferson T et al. Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No. : CD 001269. DOI: 10. 1002/14651858. CD 001269. pub 4. Evidence base

Protecting HCWs: systematic review effectiveness Outcome Number studies Number patients Relative Risk 95% CI

Protecting HCWs: systematic review effectiveness Outcome Number studies Number patients Relative Risk 95% CI Influenza-like illness 10 6984 0. 70 0. 59 -0. 83 Confirmed Influenza 8 11285 0. 27 0. 16 -0. 46 GP visits 1 1178 0. 58 0. 37 -0. 91 Hospital admission 2 2590 0. 37 0. 12 -1. 12 Pneumonia 1 1402 0. 59 0. 04 -9. 43 Working days lost 4 4263 Mean -0. 21 Mean -0. 36 to -0. 05 When circulating virus matches vaccine Jefferson T et al. Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No. : CD 001269. DOI: 10. 1002/14651858. CD 001269. pub 4. Evidence base

Protecting HCWs: systematic review effectiveness Outcome When circulating virus matches vaccine Num ber stud

Protecting HCWs: systematic review effectiveness Outcome When circulating virus matches vaccine Num ber stud ies Numb er patien ts Relat ive Risk 95% CI Influenza-like illness 10 6984 0. 70 0. 59 -0. 83 Confirmed Influenza 8 11285 0. 27 0. 16 -0. 46 GP visits 1 1178 0. 58 0. 37 -0. 91 Hospital admission 2 2590 0. 37 0. 12 -1. 12 Pneumonia 1 1402 0. 59 0. 04 -9. 43 Working days lost 4 4263 Mean -0. 21 Mean -0. 36 to -0. 05 • 73% reduction influenza in immunised HCWs • Immunised HCWs will on average take off 0. 2 days less than unimmunised HCWs • Every 5 HCWs immunised will result in an extra day staff availability to provide clinical care Jefferson T et al. Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No. : CD 001269. DOI: 10. 1002/14651858. CD 001269. pub 4.

Protecting HCWs: systematic review effectiveness • In general population healthy adults aged 16 -65

Protecting HCWs: systematic review effectiveness • In general population healthy adults aged 16 -65 years when vaccine and circulating strain match: – 4% of unvaccinated develop influenza – 1% of vaccinated develop influenza – Absolute risk difference 3% – 95% CI difference 2% to 5% Jefferson T et al. Vaccines for preventing influenza in healthy adults. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No. : CD 001269. DOI: 10. 1002/14651858. CD 001269. pub 4.

Conclusion • In an ideal world more high quality research – Larger studies in

Conclusion • In an ideal world more high quality research – Larger studies in more specific staff and/or patients groups – To demonstrate effects on less common outcomes and improve generaliseability • However, available evidence is consistent – Effective and cost effective for both staff and patients Evidence base

How are we doing? 2010 -11 influenza immunisation uptake in Occupational Health

How are we doing? 2010 -11 influenza immunisation uptake in Occupational Health

How are we doing? Improving

How are we doing? Improving

How are we doing? Improving, but some way to go.

How are we doing? Improving, but some way to go.

How are we doing? Uptake in different staff groups

How are we doing? Uptake in different staff groups

Increase uptake in HCWs • What have you done? • What worked? Share experience

Increase uptake in HCWs • What have you done? • What worked? Share experience

Why are HCWs not immunised? 21 studies in 9 countries. Weighted score. Hollmeyer FH

Why are HCWs not immunised? 21 studies in 9 countries. Weighted score. Hollmeyer FH et al. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine 2009; 27: 3935 -44.

Why are HCWs immunised? 21 studies in 9 countries. Weighted score. Hollmeyer FH et

Why are HCWs immunised? 21 studies in 9 countries. Weighted score. Hollmeyer FH et al. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine 2009; 27: 3935 -44.

Intervention to increase uptake Components Definition Examples Education or promotion Efforts to raise awareness

Intervention to increase uptake Components Definition Examples Education or promotion Efforts to raise awareness and/or increase knowledge about influenza and influenza vaccine • Educational sessions • Educational materials • Events promoting vaccination • Incentives Improved access to vaccine Strategies to allow easier access to vaccination for HCWs • Mobile vaccine carts • Peer to peer vaccination • Additional clinics • Extended opening clinics Legislation or regulation Interventions involving changes in vaccination policy for HCWs • Employer policy • Declination forms • Mandatory immunisation Measurement and feedback Tracking of uptake rates in HCWs and dissemination of results • Regular reporting uptake to managers and/or HCWs Role models Activities that involve leaders and/or senior staff to encourage vaccination • Advocates and champions • Public support • Visible immunisation Types of interventions Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010; 182(12): 542 -8.

Intervention to increase uptake Intervention Not exposed Exposed Change uptake Education or Promotion Dey

Intervention to increase uptake Intervention Not exposed Exposed Change uptake Education or Promotion Dey et al. Educational session & materials 6% 10% +4% Kimura et al. Educational Video 30% 36% +7% Lemaitre et al. Educational session & materials 32% 69% +37% 30% 49% +20% 30% 58% +29% 35% +30% Improved access Kimura et al. Free vaccine day Education + improved access Kimura et al. Educational Video & Free vaccine day Education + access +legislation + role model Hayward et al. Educational letter & out hours clinics & 5% policy & training lead nurse advocates NOTE: Rounding errors! Red statistically significant Randomised controlled trials: community Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010: 182(12); 542 -8.

Intervention to increase uptake Intervention Not exposed Exposed Change uptake Education or Promotion Doratotaj

Intervention to increase uptake Intervention Not exposed Exposed Change uptake Education or Promotion Doratotaj et al. Letter from infectious disease department 38% 39% +1% Doratotaj et al. Raffle ticket for $3000 vacation 38% 42% +4% Doratotaj et al. Letter from infectious disease department & Letter from infectious disease department 38% 45% +7% Ohrt et al. Letter from chief of infectious disease 8% 22% +14% Ohrt et al. Personalised phone call 11% 20% +9% Randomised controlled trials: hospital Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010: 182(12); 542 -8.

Intervention to increase uptake Intervention Before After Change uptake Education + improved access Tannenbaum

Intervention to increase uptake Intervention Before After Change uptake Education + improved access Tannenbaum et al. Information sessions by doctors & informational memos + posters & extra clinics 10% 24% +14% Thomas et al. Vaccination fair 8% 46% +38% Before and after trials: community Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010: 182(12); 542 -8. Talbot R. Do declination statements increase health care workers influenza vaccination rates? CID 2009; 49: 773 -9.

Intervention Before Intervention to increase uptake After Change uptake Education or Promotion Zimmerman et

Intervention Before Intervention to increase uptake After Change uptake Education or Promotion Zimmerman et al. Incentive (lottery gift card) 34% 38% +4% Zimmerman et al. Mobile vaccine cart 34% 39% +4% Sartor et al. Mobile vaccine cart 7% 32% +25% Cooper et al. Mobile vaccine cart 8% 49% +41% 23% 37% +15% Vaccines at meetings & feedback uptake to directors 58% 61% +3% Polgreen et al. Declination statement 54% 65% +11% Bertin et al. Declination statement 38% 55% +17% Ribner et al. Declination statement 43% 65% +22% Hagar Mandatory vaccination 30% 98% +68% Babcock et al. Mandatory vaccination 71% 99% +28% Improved access Education or Promotion+ improved access Harbarth et al. Educational meeting & mobile cart Improved access + measurement feedback Polgreen et al. Legislation Before and after trials: hospital Lam PP et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ 2010: 182(12); 542 -8. Talbot R. Do declination statements increase health care workers influenza vaccination rates? CID 2009; 49: 773 -9.

Mandatory vaccination • Introduced in US and Australia – ? culturally more acceptable –

Mandatory vaccination • Introduced in US and Australia – ? culturally more acceptable – US require immunisation for school attendances • In general not in keeping with UK approach – Immunity to hep B required for EPPs A step too far for the UK?

Declination statement Influenza Vaccine Declination Form Health Board / NHS Trust Name: _____________ You

Declination statement Influenza Vaccine Declination Form Health Board / NHS Trust Name: _____________ You have given me the opportunity to be vaccinated with the influenza vaccine at no cost to myself. I have received, read and understand information about the risks and benefits of the vaccine. I am eligible to receive the influenza vaccine BUT do not want to take it. I understand that by refusing the vaccine I may be putting MYSELF and my FAMILY, FRIEND, and PATIENTS at risk of getting influenza. I am aware that hospitalised patients are at increased risk of developing serious complications and death following influenza infection. However, I decline the influenza vaccine at this time. __________________ Employee’s Name (Print) ___________________ Employee’s Signature ___________________ Date Should be considered?

Conclusion • Influenza vaccination protects HCWs and their patients. • Influenza vaccination is highly

Conclusion • Influenza vaccination protects HCWs and their patients. • Influenza vaccination is highly cost effective, and potentially cost saving for the NHS. • Multifaceted interventions are required to improve uptake in the NHS in Wales. What are you going to do?

What are you going to do? Copyright Leah Millinship Organised efforts will succeed

What are you going to do? Copyright Leah Millinship Organised efforts will succeed

References • • • • Polgreen PM, Septimus EJ, Parry MF, et al. Relationship

References • • • • Polgreen PM, Septimus EJ, Parry MF, et al. Relationship of influenza vaccination declination statements and influenza vaccination rates for healthcare workers in 22 US hospitals. Infect Control Hosp Epidemiol 2008; 29: 675– 7. Bertin M, Scarpelli M, Proctor AW, et al. Novel use of the intranet to document health care personnel participation in a mandatory influenza vaccination reporting program. Am J Infect Control 2007; 35: 33– 7. Buchta WG, Verdoon CA, Schultz GL. Effectiveness of declination statements in influenza vaccination programs for healthcare workers [abstract 348217]. In: Program and abstracts of the International Commission on Occupational Health (ICOH) Conference on Health Care Worker Health/2007 State-of-the-Art Conference (Vancouver, British Columbia, Canada). International Commission on Occupational Health, 2007. Ribner BS, Hall C, Steinberg JP, et al. Use of a mandatory declination form in a program for influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol 2008; 29: 302– 8. Polgreen PM, Polgreen LA, Evans T, Helms C. A statewide system for improving influenza vaccination rates in hospital employees. Infect Control Hosp Epidemiol 2009; 30: 474– 8. Sartor C, Tissot-Dupont H, Zandotti C, Martin F, Roques P, Drancourt M. Use of a mobile cart influenza program for vaccination of hospital employees. Infect Control Hosp Epidemiol 2004; 25: 918– 22. Cooper E, O’Reilly M. A novel staff vaccination strategy. Infect Control Hosp Epidemiol 2002; 23: 232– 3. Harbarth S, Siegrist CA, Schira JC, Wunderli W, Pittet D. Influenza immunization: improving compliance of healthcare workers. Infect Control Hosp Epidemiol 1998; 19: 337– 42. Thomas DR, Winsted B, Koontz C. Improving neglected influenza vaccination among healthcare workers in long-term care. J Am Geriatr Soc 1993; 41: 928– 30. Dey P, Halder S, Collins S, Benons L, Woodman C. Promoting uptake of influenza vaccination among health care workers: a randomized controlled trial. J Public Health Med 2001; 23: 346– 8. Doratotaj S, Macknin ML, Worley S. A novel approach to improve influenza vaccination rates among health care professionals: a prospective randomized controlled trial. Am J Infect Control 2008; 36: 301– 3. Babcock HM et al. Mandatory influenza vaccination of health care workers: translating policy to practice. Clin Infect Dis 2010; 50: 459– 64. Hagar BA. 2008 42 nd NIC National Immunization Conference: Mandatory influenza vaccination: the Virginia Mason Story. Available at: http: //cdc. confex. com/recording/cdc/nic 2008/ppt/free/4 db 77 adf 5 df 9 fff 0 d 3 caf 5 cafe 28 f 496/paper 15824_5. ppt Zimmerman RK, Nowalk MP, Lin CJ, et al. Factorial design for improving influenza vaccination among employees of a large health system. Infect Control Hosp Epidemiol 2009; 30: 691 -7. Hayward AC, Harling R, Wetten S, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006; 333: 1241 Intervention studies to increase uptake