Immunizing Healthcare Workers: What Works & Why Does it Matter?

Transcription

1 Immunizing Healthcare Workers: What Works & Why Does it Matter? Amy J Behrman, MD, FACP, FACOEM Medical Director, Occupational Medicine University of Pennsylvania No disclosures

2 Immunizing Healthcare Workers: What Works & Why Does it Matter?

3 Adult Immunization How are we doing nationally? Why does it matter more for HCWs? Consensus on decreasing risk for patients and providers Moderate data on effectiveness Disagreement on how to use vaccination effectively and ethically

4 How do we disagree? Inconsistent National & State Guidelines Debate re risks and benefits Profound disagreement on mandates Flu is a flashpoint

5 INFLUENZA Why is Flu different from other vaccine-preventable respiratory viruses? Multiple hosts Very high rate of genetic variability Multiple seasonal strains circulate globally Shed by droplets and contact New strains arise frequently, varying in severity Vaccine must be repeated yearly Vaccine doesn t always match circulating strains Annual vaccine efficacy and effectiveness vary

6 Variolation - A 2-edged sword Inoculation History Rediscovery Lady Mary Montagu Istanbul 1717 London 1721 Risks and Benefits Boston 1721

7 Variolation - First Mandates HCWs British troops Germ Warfare Inoculation risk Inoculation Benefit Inoculation Mandate

8 Vaccination - A gamechanging innovation Variolation in practice Occupational Illness Edward Jenner Benefits & Risks Societal impact Entrepreneurs Philanthropy Colonialism Mandates Successes

9 Anti-Vaccine Movements Benign disease Vaccine doesn t work Disease from vaccine Class Warfare Profit Motive Civil Rights Medical Hubris Clean Bodies

10 Vaccines & HCWs Many vaccines are recommended for HCWs - unanimous re CDC, JCAHO, SHEA, ACOEM, state DOHs Some have been mandatory for years: Some have been made mandatory more recently or not yet in healthcare settings: Pertussis, varicella, influenza My goals are to Present our experience of these 2 approaches Describe evolution of our current Flu program

11 Preventing Influenza Transmission

12 Preventing Influenza Transmission Vaccination is the most effective way to prevent transmission Must be repeated to protect against each new year s circulating strains Decreased absenteeism in industry Decreased infections in nursing homes May decrease transmission to patients in healthcare settings Vulnerable patients (elderly, infants, immune compromised) have least vaccine response

13 INFLUENZA VACCINE FOR HEALTHCARE WORKERS - Outreach and Mandates Experience from a Large Urban Teaching Hospital in Pennsylvania

14 University of Pennsylvania Health System 3 Hospitals - >21,000 employees HUP 800 beds PAH 500 PPMC ,000 SF Ambulatory Practice/Surgery Outlying practices t/o SE PA >80,000 admissions; >2 million OPT visits Operational and record-keeping challenges

15 HCWs and Vaccination- How were we doing? Measles, mumps, rubella, varicella HCP and patients are at risk if not immune Long term immunity from disease or vaccine Condition of employment, assessed at hire Live virus vaccines with <100% efficacy Medical contra-indications: Pregnant or immune-compromised HCP HCW compliance approaches 100% Religious objections: rare & not accommodated

16 HCWs and Vaccination- How were we doing with flu? Influenza Killed vaccine safe, available, effective (Foppa 2015) Also recommended for HCWs for decades Infected HCWs are a risk for patients in acute & chronic care (Carman 2000, Vanhems 2011) HCW vaccination is associated with decreased ILI or mortality in acute & chronic care (Hayword, 2006, Lemaitre 2009, Shugarman 2006, Ahmed 2014). Modeling studies support similar efficacy in acute care settings (van den Dool 2008, 2009; ). HCW rates averaged <50% until recently Quality focus for HUP OM since 2004

17 HUP Voluntary Influenza Vaccine Program Free vaccine available to all HCWs Vaccination on-site in all clinical units and nonclinical sites, all shifts Vaccine at cafeteria and public hospital areas Flu fairs with education, games, & incentives Vaccine for walk-ins in OM clinic 8-12 hours/day Needle-free FluMist Vaccination Rates <45% Why were staff declining vaccine?

18 HUP Voluntary Influenza Vaccine Program Declination forms analyzed for HCW concerns Flu is not dangerous The vaccine doesn t work The vaccine will make me sick The vaccine isn t safe I don t like to put foreign things into my body I live a clean life so I won t get flu This is a plot against the staff You must be making money from this

19 Anti-Vaccine Movements Benign disease Vaccine doesn t work Disease from vaccine Class Warfare Profit Motive Civil Rights Medical Hubris Clean Bodies

20 HUP Voluntary Influenza Vaccine Program Declination forms analyzed Outreach & education via hospital newsletter, , intranet, & managers meetings 2008 Flu shot music video using hospital staff

21 HUP Voluntary Influenza Vaccine Program Results: Inadequate Improvement <45% until % % (60% of clinical staff) Barely beat the national average

22 Should Flu Vaccine be Required? Cons Nobody likes being forced esp annually Threatens HCW autonomy May reduce efforts to educate & improve voluntary vaccination and other IC measures Better voluntary programs can be created May produce resentment and adversarial feelings Expensive to monitor and enforce Some voluntary programs have achieved >80% flu vaccine rates

23 Should Flu Vaccine be Required? Pros There may be real limits to voluntary programs Even 80% coverage rates don t provide maximal risk reduction for patients and coworkers Compliance for mandated MMRV immunity approaches 100% with negligible staff objections Early mandatory influenza vaccine programs for HCWs reported >95% - doubling prior rates HCWs are generally healthy adults with optimal vaccine responses

24 Should Flu Vaccine be Required? Consensus among IC and OM staff 2008 Institutional debate and discussion of mandates to enhance patient and staff safety Early 2009 Leadership commitment Medical Boards- CMO Nursing Leadership - CNO Housestaff/GME Human Resources - CHROs Administration - EVP, Dean, Admin OGC

25 Should Flu Vaccine be Required? HUP IM/EM Physician survey spring 2009 supported a mandatory vaccine policy (DeSante et al 2010) 90% believed HCWs have an obligation to their patients to be vaccinated 85% believed HCW vaccination should be mandatory Those with more patient contact were more likely to be vaccinated, more likely to support mandates, and more likely to vaccinate their patients

26 HUP Influenza Vaccine Program New UPHS-wide policy requiring influenza vaccination for all HCWs Scope: Staff, Physicians, Contractors, Volunteers, Students Resources - supported by Educational programs, website Interactive live and electronic Q&A Exemption reviews, medical and religious Multi-faceted outreach to all all locations

27 HUP Influenza Vaccine Program Exemptions: Medical & Religious Consequences: Masking, Admin Penalties Facilitating Sick Day Utilization Aggressive testing of HCW with ILI Strict furlough for HCWs with Flu/ILI Visiting age raised Masking all ED patients and visitors

28 HUP Influenza Vaccine Program Challenges 2 vaccines, shortages, triage/rationing Sub-optimal database Some skeptical and hostile staff Geographically dispersed staff Aided by public health concerns for H1N1 Outcomes Accepted as Patient Safety/Staff Safety initiative 99.3% seasonal influenza vaccination 69% H1N1 vaccination (limit of supply)

29 HUP Influenza Vaccine Program Stable level of staff objection Single vaccine; No supply issues Decrease in public health and media Accepted as Patient & Staff Safety Program Strong PA State support >98% seasonal influenza vaccination Exemptions stable <1% acute care <2% nonclinical areas

30 HUP Influenza Vaccine Program Exemptions standardized & review simplified Consequences Masking dropped Exempted staff transferred from high risk areas Noncompliance addressed by suspension, loss of raises, potential job loss No Terminations to date Stable level of resentment (Vent Lunch) but much less anxiety Minimal /No pushback on 2014 efficacy

31 CDC HCW Influenza Vaccination MMWR September 18, 2015 / 64(36);

32 Conclusions, Comments, Questions HCWs have a professional obligation to minimize risks for patients (and colleagues) Professionalism extends beyond direct clinical staff Mandates are the most effective way to maximize immunity for HCWs (Rakita et al 2010, Babcock et al 2010, Talbot et al 2010, Hollmeyer et al 2012) Mandates may paradoxically allay anxiety among some staff Mandates may help prepare for pandemics

33 Conclusions, Comments, Questions Are vaccines (including influenza) effective in reducing risk for patients and staff? LTC versus Acute Care ILI versus laboratory diagnostics HAI, employee flu, absenteeism, presenteeism Year to year variability Comparison with other vaccines Comparison with other IC interventions Are mandates effective? YES Are mandates ethical? YES Are we repeating past errors? YES

34 Conclusions, Comments, Questions Immunizations, controversy & mandates have been part of human narrative for >300 years Don t try to silence detractors and skeptics - Listen respectfully, respond rationally Emotional stakes are high on both sides Misinformation and anxiety are common - perhaps most so for new and non-mandated vaccines Education and outreach are crucial but probably won t lead to full consensus

35 Conclusions, Comments, Questions Vaccination is not claimed to be an invariable preventive but in a majority of cases successful 1892 I will try to arrange the funerals {of doctors not vaccinated for smallpox} with all the pomp and ceremony of an anti-vaccination demonstration 1910 As far as vaccine therapy {for influenza} was concerned, we did not deem it worthy of trial 1918