1 INFLUENZA IMMUNIZATION IN YORK REGION: RATES OF UPTAKE AMONG HEALTH CARE WORKERS IN HOSPITALS AND LONG-TERM CARE HOMES

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1 1 INFLUENZA IMMUNIZATION IN YORK REGION: RATES OF UPTAKE AMONG HEALTH CARE WORKERS IN HOSPITALS AND LONG-TERM CARE HOMES The Health and Emergency Medical Services Committee recommends the adoption of the recommendation contained in the following report, August 23, 2005, from the Commissioner of Health Services: 1. RECOMMENDATION It is recommended that: 1. York Region Health Services (YRHS) staff take appropriate measures as detailed in this report to increase the uptake of annual influenza immunization in the community and improve the rates of influenza immunization among health care workers (HCWs) employed in hospitals and Long-Term Care Homes (LTCHs) in the Region. 2. PURPOSE The purpose of this report is to: Explain the importance of annual influenza immunization. Provide a summary of influenza immunization activities from 2000 to Outline proposed strategies for the influenza season to improve annual uptake of influenza immunization in the community and by HCWs employed in LTCHs and hospitals in York Region. 3. BACKGROUND Influenza is a highly contagious virus that is a leading cause of respiratory illness. In Canada, influenza season typically runs from November to April, and an estimated 10-25% of Canadians may contract influenza each year. Influenza can cause significant morbidity, particularly in children under 2, people over 65, and people with underlying health conditions. Transmission of influenza in hospitals and LTCHs has been well documented, with significant impacts on patient and resident morbidity and mortality. Indirect effects of institutional influenza outbreaks include the disruption of normal operations, shortages of HCWs, and fewer elective admissions to hospitals. According to the Ministry of Health and Long-Term Care (MOHLTC), annual immunization is the most effective way to reduce the impact of influenza, especially for persons at high risk or those potentially capable of transmitting influenza to those at high risk.

2 The MOHLTC issued an Influenza Surveillance and Prevention Protocol to Ontario nursing homes and homes for the aged in November, This was followed by an Influenza Surveillance Protocol for public hospitals in July of Both protocols require that facilities have a policy to address influenza surveillance, prevention (including annual immunization), and outbreak control. All Long-Term Care Facilities and public hospitals are required to report their influenza vaccine coverage rates to the local medical officer of health annually before December 1 st. YRHS is mandated by the MOHLTC to promote influenza vaccination to all eligible staff and residents in nursing homes, homes for the aged and chronic care hospitals or units, with the goal of increasing to 70 % the annual influenza vaccination coverage of health care workers in contact with high-risk individuals (Mandatory Health Programs and Services Guidelines, 1997). The National Advisory Committee on Immunization (NACI), which advises the Public Health Agency of Canada on issues related to immunization, recommends that influenza vaccine programs should aim to vaccinate at least 90% of eligible recipients. However, uptake of influenza immunization among HCWs remains purely voluntary as there is no current Federal or Provincial legislation on mandatory vaccination. This poses a challenge for public health officials since they are responsible for increasing influenza vaccine coverage, without the authority to mandate vaccination. 4. ANALYSIS AND OPTIONS 4.1 Current Influenza Immunization Programs Influenza Immunization in the Community Through the MOHLTC s Universal Influenza Immunization Programs (UIIP), influenza vaccine has been made available annually to all Ontario residents free of charge since the fall of As the table below demonstrates, the uptake of free influenza immunizations provided by YRHS has been increasing since that time.

3 Table 1 Universal Influenza Immunization Program (UIIP) in York Region Influenza Season Population* 713, , , , ,214 UIIP Summary** Doses distributed for UIIP Rate per 1000 Population York Region Flu Clinics 220, , , , , Number of Clinics Doses administered at Clinics 1,512 4,279 5,862 12,037 14,409 * Source: Provincial Health Planning Database (PHPDB), Health Planning Branch, Ontario Ministry of Health and Long-Term Care, July 19, 2004 ** Includes doses distributed to York Region physicians and administered at York Region flu clinics Through the UIIP, YRHS offers free influenza immunization to any person over the age of six months in clinics held in shopping centres, seniors centres, and community centres. These clinics are advertised in a variety of media and locations, such as transit ads, newspaper ads, and flyers sent home with children in school and daycare. A formal evaluation of the YRHS community influenza immunization program was conducted to identify successful marketing practices and other efficient strategies in order to make the best use of resources. Community stakeholders, including clients, physicians, nursing agencies, and centres where clinics are held, provided input into ways to expand the scope of clinics to more elderly and disabled clients, and to more cultural groups. These suggestions will be used to guide the program Influenza Immunization in Health Care Workers The National Advisory Committee on Immunization (NACI) recommends that influenza immunization programs focus on those at high risk of influenza-related complications, those capable of transmitting influenza to individuals at high risk of complications, and those who provide essential community services. Influenza immunization of HCWs has been shown to lower mortality among patients for whom they provide care, especially the elderly and other at-risk individuals. NACI recommends that annual influenza

4 immunization be required for all HCWs unless medically contraindicated, and states that refusal of HCWs, who are involved in direct patient care, to be immunized against influenza implies failure in their duty to provide care for their patients. However, there are no current regulations for mandatory immunization of HCWs. YRHS has been promoting influenza immunization in Regional hospitals primarily in conjunction with hospital Infection Control Practitioners (ICPs), whose responsibility it is to immunize the risk of infection for hospital patients, employees, and visitors. Bi-monthly meetings are held with hospital ICPs in order to discuss infection control issues including controlling the spread of influenza. For Regional LTCHs, which do not have ICPs in their staff, YRHS promotes influenza immunization in employee in-services and an annual Education Day. Hospital ICPs also participate in Education Days. Nevertheless, as the tables below demonstrate, voluntary annual uptake of the influenza vaccine by HCWs in some institutions in the Region remains below the NACIrecommended level of 90%, particularly among those working in acute care facilities. Table 2 Influenza Immunization Rates in Hospital Staff in York Region Hospital Markham- Stouffville Hospital Influenza Season % 40.3% 41.9% 45.0% 43.1% Shouldice Hospital NA NA NA 34.7% 38.2% Southlake Regional Health Centre York Central Hospital 34.0% 30.2% 34.2% 34.7% 32.2% 45.7% 38.3% 27.3% 53.5% 35.6% Table 3 Influenza Immunization Rates in LTCH Staff in York Region LTCH Influenza Season Aurora Resthaven 94.5% 95.2% 97.8% 88.4% 95.4% Bethany Lodge 77.2% 50.5% 67.7% 77.7% 51.6%

5 Bloomington Cove 85.2% 89.1% 70.2% 49.0% 48.9% Cedarvale Lodge 85.1% 69.9% 85.0% 73.0% 90.4% Eagle Terrace 96.9% 92.3% 68.1% 88.5% 95.2% Elginwood 64.6% 54.2% 49.0% 44.0% 35.0% King City Lodge 95.3% 100% 74.4% 97.1% 100% Kristus Darsz Latvian Home 80.2% 88.6% 82.1% 73.6% 87.2% Leisureworld Richmond Hill NA NA NA 46.3% 41.1% Leisureworld Vaughan NA NA NA NA 88.2% Mackenzie Place 70.3% 88.5% 81.0% 88.9% 82.8% Mariann Home 84.8% 68.9% 85.9% 86.7% 87.9% Markhaven 94.4% 94.3% NA NA 78.0% Mon Sheong NA NA NA 98.0% 97.6% Parkview Home 91.4% 91.4% 89.7% 87.5% 93.2% Pine Grove Lodge 45.7% 73.0% 52.8% 71.0% 69.8% River Glen Haven 61.5% 64.6% 74.5% 70.6% 65.8% Sherwood Court NA NA NA 73.8% 33.0% Southlake Residential Care 90.5% 84.5% 91.1% 80.1% 83.5% Union Villa 99.6% 99.1% 74.6% 59.0% 79.3% Villa Leonardo Gambin NA NA NA NA 52.9% Willows Estate 61.9% 70.9% 83.3% 59.5% 72.4% Woodhaven NA NA NA 36.8% 86.5% Yee Hong NA NA 98.4% 98.5% 97.9% York Central Hospital 45.6% 91.4% 81.7% 89.4% 83.0% Extendicare YR- Maple Health Centre 95.4% 99.4% 97.2% 69.6% 63.1% YR- Newmarket Health Centre 92.9% 95.0% 94.5% 96.2% 85.2%

6 Proposed Strategies The following strategies will be implemented for the flu season Influenza Immunization in the Community YRHS will draw on the recommendations of the evaluation of the influenza immunization program in developing its program, including the following: Five additional community influenza clinics are planned in Alternative Community Living Centres, specifically targeting high-risk home-bound seniors. This will also address responsibilities outlines in the Ontarians with Disabilities Act. Influenza immunization clinics will be promoted in more languages to more cultural groups (for example, a clinic will be held at the Chinese Open House in November). YRHS will include promotional materials when they distribute UIIP vaccine to physicians in the Region. YRHS will also link with provincial pandemic flu planning initiatives to develop strategies, including a media campaign, to communicate the importance of annual influenza immunization Influenza Immunization in HCWs YRHS will collaborate with staff in hospitals and LTCHs in order to develop strategies for improving rates of annual influenza immunization of HCWs in the flu season. Proposed strategies include, but are not limited to: Identifying barriers to staff influenza immunization through consultation with communication personnel and staff. Providing education. Contributing to policy development and communication plans. Monitoring and disseminating staff immunization rates. Since the issues may be different in hospitals and LTCHs, YRHS staff will approach these two groups separately. Facilities with the lowest rates will be specifically targeted. 4.3 Relationship to Vision 2026 Improving influenza immunization uptake in the community and improving rates of influenza immunization among HCWs in LTCHs and hospitals in the Region will support the Vision 2026 goal of responding to the needs of our residents. 5. FINANCIAL IMPLICATIONS The program activities described in this report will be funded from the approved 2005 Health Services Business Plan and Budget. The MOHLTC reimburses YRHS $5 per dose of influenza vaccine provided at community flu clinics. For the season this amounted to $72,045 of funding from the MOHLTC (for 14,409 shots), which covered the direct costs of delivering this York Region clinical service.

7 6. LOCAL MUNICIPAL IMPACT Improving annual influenza immunization rates in the community and in HCWs in hospitals and LTCHs will positively impact the health of residents of the Region. Greater uptake of influenza immunization in the community will reduce morbidity and mortality associated with community transmission of the disease. Higher rates of annual influenza immunization in HCWs will reduce the morbidity and mortality associated with nosocomial influenza outbreaks, and will contribute to the greater health of residents, patients, and staff. High levels of influenza immunization coverage in the community may also provide some cross-protection in the event of an outbreak of a pandemic strain of influenza. 7. CONCLUSION High rates of annual influenza immunization are crucial to protect the health of residents of the Region. YRHS should implement further strategies in the community and collaborate with hospitals and LTCHs to optimize annual influenza vaccine uptake. The Senior Management Group has reviewed this report.