Experiences with a mandatory masking program for unvaccinated health care workers (HCWs) Amy Pine, MPH Director, Communicable Disease Prevention Unit

Transcription

1 Experiences with a mandatory masking program for unvaccinated health care workers (HCWs) Amy Pine, MPH Director, Communicable Disease Prevention Unit April 23, 2012

2 Background Studies show that long term care facilities with higher rates of influenza vaccination among HCWs have lower incidence of influenza related mortality among patients (Carman et. al, 2000). At least one study shows that unvaccinated, unmasked pre symptomatic HCWs had direct contact with patients who subsequently developed influenza (Marquez et. al, 2009). CDC and ACIP have recommended annual influenza vaccination for HCWs since 1981; however, national survey data demonstrated only slight increases in coverage levels (MMWR, 2010).

3 Background Fall/Winter 2009 San Francisco Department of Public Health (SFDPH) begins implementing mandatory masking for unvaccinated HCWs at hospitals and long term care facilities ( season). Continues annually September, 2011: Memorandum ( Masking Memo ) issued to SF health care facilities.

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5 Legal contexts In California (CA Health and Safety Code Section ): Each health officer knowing or having reason to believe that any case of the diseases made reportable by regulation of the department, or any other contagious, infectious or communicable disease exists, or has recently existed, within the territory under his or her jurisdiction, shall take measures as may be necessary to prevent the spread of the disease or occurrence of additional cases.

6 Memo Dissemination Hospital CEOs VaxFax to all hospital infection control and long term care facilities To infection control practitioners via Infection Control Working Group (ICWG) Also presented the memo at one of ICWG meetings and provided technical assistance on several calls Via Director of Health list serves through SFDPH

7 1. Determine flu season infection control strategies implemented by facilities in San Francisco. 2. Determine how many facilities (hospitals and LTCFs) in San Francisco implemented masking requirements in accordance with the Masking Memo. 3. Summarize implementation strategies employed by facilities implementing masking requirements. 4. Identify any challenges faced or successes achieved in implementation of masking strategies 5. Gauge facilities reactions to the Masking Memo, and evaluate how SFDPH can work with facilities to improve flu season programs in the future. PURPOSE OF EVALUATION

8 Methods: Data collection in 3 Parts 1. Questionnaire Fax back Survey sent to 8 hospitals, 26 longterm care facilities 2. Vaccination rates and staff numbers 3. Qualitative interview Telephone, 5 15 min Telephone, min All facilities who returned the survey. 10 facilities, randomly sampled from facilities who returned the faxback and agreed to further contacted. Was masking implemented? Strategies used to differentiate vaccinated and unvaccinated staff. Strategies used to implement masking program. Who was required to mask, and in which situations. Percent of staff who received flu vax , , Total number of staff General flu season activities Masking policy experience Successes and challenges Opportunities for SFDPH to improve facilities flu season programs.

9 FINDINGS

10 Findings: Facilities surveyed Facility type Surveys distributed Surveys returned Vacc. rates obtained Qualitative interviews performed Hospitals 8 7 (88%) 7 5 Long term care facilities (77%) 18* 5 Total (79%) * 18 LTCFs provided vaccination information for at least one year queried. Only 9 LTCFs provided vaccination information for all three years.

11 Facilities implementing masking policies (n=34) Hospitals: 6/8 (63%), masking policy, 1/8 (13%), no masking policy 1/8 (13%), unknown LTCFs: 12/26 (46%), masking policy 8/26 (31%), no masking policy 6/26 (23%), unknown

12 Facilities participating in evaluation, by number of employees (n=27)

13 Why did some facilities not implement masking policies? (n=9) Reason N % Did not receive memo 1 11% High staff vaccination rates, unnecessary 2 22% Facility not ready 1 11% Needed more guidance 2 22% Facility leadership decided against implementing 2 22% Unknown 1 11%

14 Findings: Who masked? (n=18)

15 Vaccination Rates (n=25) Year Hospitals LTFCs Median (n) Range Median (n) Range 75.5% (n=6) [ %] 80.0% (n=11) [ %] 78.6% (n=7) [ %] 90.0% (n=16) [ %] 81% (n=7) [ %] 90.0% (n=17) [ %] Note: Some facilities did not report all three years of vaccination rates. For this reason, sample size may not be consistent across flu years.

16 Staff vaccination rates, median by category

17 Median change in vaccination rates, to Masking No masking Hospitals +15% 29% LTCFs +4% +2% * None of the differences were statistically significant using the Wilcoxon signed rank test.

18 Masking Program strategies : differentiating vaccinated vs. unvaccinated staff * Categories are not mutually exclusive. All but one hospital used stickers to indicate staff members vax status, whereas only 1 LTCF did. Generic stickers vs. specialized stickers Sticker design coordinated across hospitals Both types of facilities relied on both the honor system and staff monitoring.

19 Masking Program strategies implemented: Logistics Hospitals more likely to provide incentives for receiving vaccination than were LTCFs. Other strategies included: Presenting requirement at staff meeting (3) One on one meetings with noncompliant staff (2) * Categories are not mutually exclusive.

20 Qualitative Findings: Flu season challenges Logistics of flu vaccination clinics Expenses Vaccines Masks Management of flu vaccination status data Vaccination policy stragglers Enforcement of policy on volunteers and visitors Dissemination of information Facilities Staff SFDPH Facilities

21 Discussion While many hospitals already had policies in place and were minimally impacted by the memo, some LTCFs felt they had to create policies from scratch. Output (vaccination rate and # of declination forms) vs. outcome (# of nosocomial flu infections)

22 Limitations Small sample size Reporting bias Other factors could account for change in vaccination rates Externalities changes at one facility may impact other facilities

23 Recommendations Improvements to memo and distribution Be more clear about intended audience Provide simple bullet points in multiple languages that can be shared with staff Make recommendations on masking specifics (e.g. w/in 3 ft of patient, who to mask) for facilities with less infection control knowledge Update existing distribution lists to include all facilities Provide additional tools for implementation via website Act as cheerleaders and facilitate discussions about best practices

24 References Carman WF., Elder A., Wallace L., McAulay K., Walker A., Murray G., Stott S. (2000). Effects of influenza vaccination of health care workers on mortality of elderly people in long term care: a randomised controlled trial. Lancet, 355 (9198), Centers for Disease Control and Prevention. (2006). Influenza vaccination of health care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HIPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR, 55 (No. RR 2), 3 4. Interim Results: influenza A (H1N1) 2009 Monovalent and Seasonal Influenza Vaccination Coverage Among Health Care Personnel United States, August 2009 January MMWR 2010;59(12): Marquez, P., Terashita, D., English, L., Dassey, D. E., Mascola, L. (n.d.). Pre symptomatic healthcare worker transmission of pandemic (H1N1) influenza in acute care settings. Retrieved 2 7, 2011, from Talbot TR., Dellit TH., Hebden J., Sama D., Cuny J. Factors associated with increased healthcare worker influenza vaccination rates: results from a national survey of university hospitals and medical centers. Infect Control Hosp Epidemiology 2010; 31(5):

25 THANK YOU