Wednesday, January 13, :00 PM ET. Agenda. Immunization of Healthcare Personnel: Preventing Disease Transmission at the Critical Link

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1 Vaccination for Healthcare Professionals Wednesday, January 13, :00 PM ET Agenda Agenda Welcome and Introduction William Schaffner, MD, NFID Medical Director Immunization of Healthcare Personnel: Preventing Disease Transmission at the Critical Link William L. Atkinson, MD, MPH, Associate Director for Immunization Education, Immunization Action Coalition Communicating with Healthcare Professionals About Their Vaccination Patricia (Patsy) A. Stinchfield, MS, CPNP, CIC, Director of Infection Prevention & Control, Children s Hospitals and Clinics of Minnesota Questions and Answers 1

2 General Information Please note that today s webinar is being recorded All phone lines will be placed on mute throughout the program To hear audio: Computer: Follow directions Phone: ; Access Code After the presentations, there will be a Question and Answer period Use the Chat box on the lower left side of your screen to type your question At the end of the webinar, participants will be directed to an online evaluation CME Credit/Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit TM. Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test 2

3 Disclosures Marla Dalton (NFID staff, content reviewer) owns stock, stock options, or bonds from Merck & Co., Inc. William Schaffner (NFID medical director, content reviewer) served as an advisor or consultant for Merck & Co., Inc. Novavax, and Pfizer Inc.; and served as a speaker or member of a speaker s bureau for Merck & Co., Inc. All other faculty, activity planners/reviewers, and staff for this activity have no relevant financial relationships to disclose Learning Objectives At the conclusion of this webinar, participants will be able to: Identify vaccines recommended for healthcare professionals (HCPs) by the Advisory Committee on Immunization Practices (ACIP) Outline factors that influence acceptance of vaccines by HCPs and apply methods and strategies to approach HCPs with differing views on vaccines to improve uptake Describe the effectiveness of strategies to improve HCP uptake of vaccines in healthcare settings 3

4 About NFID Non-profit 501(c)(3) organization dedicated to educating the public and healthcare professionals about causes, treatment, and prevention of infectious diseases across the lifespan Reaches consumers, health professionals, and media through: Coalition-building activities Public and professional educational program Scientific meetings, research, and training Longstanding partnerships to facilitate rapid program initiation and increase programming impact Flexible and nimble organization Immunization of Healthcare Personnel: Preventing Disease Transmission at the Critical Link William L. Atkinson, MD, MPH Immunization Action Coalition St. Paul, MN 4

5 Why Are We Talking About This? Work in healthcare increases the risk of exposure to several vaccine-preventable diseases Susceptible healthcare personnel (HCP) endanger themselves, their patients and their contacts Outbreaks in healthcare facilities can be dangerous and costly MMWR 2011;60(RR-7):1-19 Healthcare-Associated Measles Outbreak, Arizona, cases, 7 were acquired in hospital settings (EDs, inpatient) One unvaccinated HCP acquired measles and infected a patient who required ICU care 25% of 7,195 HCPs lacked documented evidence of measles immunity 139/1,583 (9%) of those tested were measles IgG negative Response costs in 2 affected hospitals was ~$800,000 or >$100,000 per case investigated J Infect Dis (11):

6 Vaccines* Recommended for All Healthcare Personnel Hepatitis B Influenza Measles, mumps, and rubella Varicella Pertussis *or evidence of immunity in some cases. MMWR 2011;60(RR-7):23. 6

7 Hepatitis B Evidence of Immunity Written documentation of a properly spaced 3 dose series of hepatitis B vaccine, and Confirmation of immunity (antibody to hepatitis B surface antigen [anti-hbs] >10 miu/ml) 1 to 2 months after the third dose CDC recommends that HCPs have both documentation of vaccination and a positive anti- HBs HCPs lacking documentation of vaccination should be considered unvaccinated MMWR 2013;62(RR-10):1-19 Hepatitis B Postvaccination Serologic Testing HCPs who have contact with blood or other body fluids or who are at risk for injury from blood-contaminated equipment should be tested for antibody to hepatitis B surface antigen (anti-hbs) 1 to 2 months after the third dose of vaccine MMWR 2013;62(RR-10):1-19 7

8 The New Hepatitis B Serology Issue: HCP Vaccinated as Infants or Adolescents Routine hepatitis B vaccination of infants was first recommended in 1991 Catch-up vaccination of adolescents recommended in 1995 Vaccination coverage among monthold children first exceeded 90% in 2000 The oldest cohorts vaccinated as infants are now in their early 20s Routine serologic testing of infants is not recommended (except if mother is HBsAg positive) MMWR 2013;62(RR-10):1-19 MMWR 2013;62(RR-10):1-19 8

9 MMWR 2013;62(RR-10):1-19 Hepatitis B Vaccine and HCPs Management of HCPs who have written documentation of a complete series of hepatitis B vaccine doses in the past who were not tested for antibody response following the vaccination series and who now test negative for anti-hbs administer 1 dose of hepatitis B vaccine then test for anti-hbs 1 to 2 months later if positive (anti-hbs >10 miu/ml) the person is immune and nothing else needs to be done MMWR 2013;62(RR-10):1-19 9

10 Management of Nonresponse to Hepatitis B Vaccine For persons who remain seronegative after the booster dose - complete a second series of three doses (i.e., 2 more doses) - use the usual schedule of 0, 1 and 6 months - retest for anti-hbs 1 to 2 months after completing the second series 69% of initial nonresponders will develop seroprotection after 3 revaccination doses MMWR 2013;62(RR-10):1-19 Persistent Nonresponse to Hepatitis B Vaccine ACIP does not recommend revaccination with more than 3 doses (i.e., more than 6 total doses) Check HBsAg and anti-hbc status if not already done If exposed, treat as nonresponder with HBIG postexposure prophylaxis MMWR 2013;62(RR-10):

11 MMWR 2013;62(RR-10):1-19 Hepatitis B Serologic Testing HCPs who have written documentation of a complete 3 (or more) hepatitis B vaccine series AND subsequent postvaccination anti-hbs >10 miu/ml are considered to be immune Immunocompetent persons have longterm protection against HBV infection and do not need further periodic testing to assess anti-hbs levels MMWR 2013;62(RR-10):

12 Influenza Vaccine Recommendations Routine annual influenza vaccination is recommended for all persons age 6 months and older who do not have a contraindication Healthcare providers are a high priority for annual influenza vaccination HCP may receive either inactivated and live attenuated vaccine as age- and conditionappropriate MMWR 2015;64: Live Attenuated Influenza Vaccine (LAIV) Approved only for healthy persons 2 through 49 years of age Transmission of LAIV in a healthcare setting has not been reported LAIV can be used for HCPs who work in any setting, except those who care for severely immunocompromised hospitalized persons who require care in a protective environment (e.g., a hematopoietic cell transplant unit) MMWR 2013;62 (RR-7):29 12

13 Measles, Mumps and Rubella Immunity All persons who work in medical facilities should be immune to measles, mumps, and rubella - written documentation of 2 doses of measles and mumps vaccine separated by at least 28 days and one dose of rubella vaccine on or after the first birthday, or - laboratory evidence of immunity, or - born before 1957 (except women of childbearing age)* *non-outbreak conditions MMWR 2011;60(RR-7)10-14 Measles Serologic Testing Serologic testing for immunity is not recommended for HCPs who have 2 documented doses of MMR vaccine or other acceptable evidence of immunity to measles In the event that a HCP who has 2 documented doses of MMR vaccine is tested serologically and determined to have negative or equivocal measles titer results, it is not recommended that the person receive an additional dose of MMR vaccine Such persons should be considered to have presumptive evidence of measles immunity Documented age-appropriate vaccination supersedes the results of subsequent serologic testing MMWR 2011;60(RR-7)

14 Acceptable Evidence of Varicella Immunity Among HCPs Written documentation of age-appropriate vaccination Laboratory evidence of immunity or laboratory confirmation of varicella disease Healthcare provider diagnosis or verification of varicella disease History of herpes zoster based on healthcare provider diagnosis Birth in the US before 1980 is not acceptable as evidence of immunity for HCPs MMWR 2007;56(RR-4):16-17 Varicella Serologic Testing Serologic testing before vaccination may be cost-effective Routine testing for varicella immunity after 2 doses of vaccine is not recommended Commercial assays are often not sensitive enough to detect antibody after vaccination Documented age-appropriate vaccination supersedes the results of subsequent serologic testing MMWR 2011;60(RR-7):

15 Tdap Vaccine and Healthcare Personnel All previously unvaccinated HCPs, regardless of age*, should receive a single dose of Tdap as soon as feasible Either brand of Tdap may be used* Priority should be given to vaccination of healthcare personnel who have direct contact with infants 12 months of age and younger Both brands of Tdap are currently licensed and recommended for one dose *off-label recommendation for Adacel MMWR 2011;60 (No. 1):13-5 Tdap Revaccination Revaccination with Tdap applies ONLY to pregnant women Does NOT apply to family members or other contacts ACIP does not recommend Tdap revaccination for HCPs Focus on current Tdap program - improve adult Tdap coverage, including HCPs (31% in 2012) - vaccination of pregnant women MMWR 2013:62(No.7):

16 Immunization of HCPs Summary Hepatitis B- vaccination and serology Influenza- annual vaccination MMR- vaccination or serology, not both Varicella- vaccination or serology, sometimes both (for older persons with uncertain disease history) Tdap- one dose for all HCPs Resources General Recommendations on Immunization. MMWR 2011;60(RR-2):1-61 Immunization of Healthcare Workers. MMWR 2011;69(RR-7):1-45 CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management. MMWR 2013;62(RR-10):1-19 Influenza Vaccination of Healthcare Personnel. MMWR 2006;55(RR-2):1-18 Immunization Action Coalition 16

17 Communicating with Healthcare Professionals About Their Vaccination NFID Webinar January 13, 2016 Patsy Stinchfield, MS, CPNP, CIC Director, Infection Prevention & Control Nurse Practitioner, Infectious Disease and Immunology What does the law require for HCPs? Federal There is no federal law that requires HCPs to be vaccinated ACIP notes HCP as an indication on the adult schedule uniquely OSHA blood borne pathogen standard states employers are required to offer hepatitis B vaccine to staff who may be exposed to blood or other potentially infectious materials as part of their job duties but the vaccine is not required. If declined, a declination form must be signed State Many states have HCP flu vaccination laws. See CDC Public Health Law Assessment requirements (N = 7) Administrative requirements for offering vaccination (N =10) Administrative requirements for ensuring vaccination (N = 8) Surgical mask requirements (N = 3)

18 Examples of State Laws by Type 17 states have HCP flu vaccination laws of various types CDC Public Health Law, Menu of State Hospital Influenza Vaccination Laws, Nov 2015 Assessment New York: document influenza vaccination status of all personnel for the current flu season in each HCP personnel record Administrative offer Nebraska: each acute hospital shall annually offer onsite flu vaccine to all hospital employees Administrative ensure Massachusetts: hospitals shall ensure all personnel are vaccinated with seasonal influenza vaccine unless an individual declines vaccination Surgical Mask Rhode Island: HCPs who are not immunized will be required during any declared period in which flu is widespread -as part of his or her professional licensing obligation-to wear a surgical face mask for the duration of each direct patient contact Other Influencers Regulatory agencies Joint Commission s detailed standard but stops short of mandating Individual hospitals and health system conditions of employment -mandates Professional Society Position Statements-support mandatory influenza vaccine for HCPs American Academy of Pediatrics (AAP), October 2015 AAP reaffirms support for a mandatory influenza immunization policy fore all HCPs...coverage has risen to 75% in 2014 but below the goal of 90% Healthy People Mandatory influenza immunization for all HCPs is ethical, just, and necessary to improve patient safety. It is a crucial step in efforts to reduce healthcare-associated influenza infections

19 Joint Commission on Communication in Healthcare Settings Effective communication is a characteristic of organizational culture; what the organization s leaders say and how they behave may be the most important influence on this culture The Joint Commission. The Joint Commission Guide to Improving Staff Communication. Joint Commission on the Accreditation of Health Care Organizations Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention (CDC) Professional Obligation: First do no harm

20 One healthcare-associated influenza death can change minds What Factors Influence HCPs to Get their Flu Vaccine?

21 HCPs Balance Risk and Benefit of Vaccines like the General Public Hesitant vaccine decisions attributed to: Concerns vaccine safety Perceptions risks vaccine high Perception risk disease low Even when they believe vaccines are important for protectionthey still may have concerns about vaccine safety. LISTEN FIRST. Honest answers. Perception of risk changes as the season s severity emerges. Benin et al Pediatrics 2006;117: Freed et al Pediatrics 2010;125: Kwok R. The real issues in vaccine safety. Nature 2011;473: Larsen et al. Addressing the vaccine confidence gap. Lancet 2011; 378(9790): Assessing Readiness to Communicate/Hear Vaccine Messages Knowledge Attitudes Beliefs Values Experiences LISTEN FIRST

22 HCPs: Factors Associated Influenza Vaccine Uptake knowing that the vaccine is effective being willing to prevent influenza transmission believing that influenza is highly contagious believing that influenza prevention is important having a family that is usually vaccinated Riphagen-Dalhuisen J, Gefenalte G, Hak E Occup Environ Med 2012;69: Influencing Communication in Healthcare requires communicating well with: Individuals-assertive, active listening, negotiating. Consider human factors stress, fatigue, interruptions Teams-focus on patient safety, sense of pride, and teamwork. Different skills and education require careful communication Organizations-trusting, transparent culture. Values safety of patients and staff The Joint Commission Guide to Improving Staff Communication. Joint Commission on the Accreditation of Health Care Organizations Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention (CDC)

23 The Influencer Model: Motivate Influencer: The Power to Change Anything by Kerry Patterson et al What Methods and Strategies Work? Helge Hollmeyer, Frederick Hayden, Anthony Mounts, Udo Buchholz. (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza and Other Respiratory Viruses 1. Commitment of and strong support by the hospital s top management 2. Pre-intervention information collection to identify important barriers to vaccination 3. Tailoring of the program to profession, gender, race 4. Provision of free vaccine 5. Organization of easily accessible vaccine, for example, through flexible and worksite delivery

24 What Works? Helge Hollmeyer, Frederick Hayden, Anthony Mounts, Udo Buchholz. (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza and Other Respiratory Viruses 6. Organizing activities around educational material, education session, reminders, incentives 7. Management optimization, such as (i) assignment of (one or more) dedicated staff to organize and actively promote the measure, and/or (ii) giving feedback of vaccination uptake rates during the preparation phase for the influenza season 8. In a well-prepared setting: requirement of all HCW to become vaccinated against influenza with the possibility to opt-out by signing a declination statement 9. Continuation of the assessment planning intervention cycle for several years Influenza Vaccination Rates, Children's Hospitals and Clinics, November 23, Vaccinated Declined Unknown Pediatrics Critical Care Surgery Ambulatory *Vaccinated rates calculated by total number vaccinated at Children s or elsewhere divided by staff minus staff contraindicated for influenza vaccination

25 Storytelling: Seasonal influenza Wednesday, January 31, 2007 Television news airs photos a family has shared of their 8 year old son Lucio who died of Influenza A His parents hope is to alert parents in order to prevent other children from dying Droves of parents called providers concerned asking for influenza vaccine Telling the real stories makes a difference What Works? Helge Hollmeyer, Frederick Hayden, Anthony Mounts, Udo Buchholz. (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza and Other Respiratory Viruses 10.Culturally sensitive education on risk and benefit of vaccination 11. Message tailored to specific professional characteristics 12.HCW who have rejected the vaccine in previous years may be particularly resistant; aiming for high rates of coverage will need to target this group of HCW 13.Hospital managers who consider influenza vaccination uptake rates in their employees as a quality marker for their facility should be prepared to commit the required human and financial resources to meet this goal

26 Information Exchange between HCPs Needs to Be: Complete It answers all questions asked to a level that is satisfactory to those involved in the exchange of information Concise Shorten or omit wordy expressions; include only relevant statements; avoid unnecessary repetition Concrete The words used mean what they say; they are specific and considered. Give accurate facts/figures Clear Short, familiar, conversational words are used to construct effective and understandable messages Accurate The level of language is apt for the occasion; ambiguous jargon is avoided, as are discriminatory or patronizing expressions The Joint Commission Guide to Improving Staff Communication. Joint Commission on the Accreditation of Health Care Organizations Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention (CDC)

27 SBAR Example-Your Elevator Speech Situation Influenza is a dangerous disease. And flu vaccine is our best tool to prevent it. Background We can pass the flu 1 day before we even know we are sick. Getting the flu may mean being out of work for a week or more. Flu vaccine does not cause the flu. Patients die of influenza. We can transmit it to them. Assessment Influenza is a vaccine-preventable disease that can be severe for your patients, you, and your family. Flu vaccines are safe and effective to avoid the flu. Recommendations Get vaccinated every year in the fall before the flu season begins and strongly encourage everyone 6 months of age and over to get vaccinated. IHI Patient Safety Communication Method Communicating when Differing Views I don t think influenza vaccines work! It is not 100% but if you don t get a vaccine it will be ZERO effective. Kids who get flu vax have a 74% REDUCED chance of ending up in ICU It works against 3-4 strains of a serious virus but not all of the common cold viruses

28 Communicating when Differing Views I am afraid of the side effects Soreness, redness, mild achiness for 1-2 days is what to expect with the vaccine If you decide to get the vaccine, you decrease your chances of getting flu and giving it to your patients Communicating when Differing Views I don t need a flu vaccine Everyone 6 months of age or older would benefit from being vaccinated Patients you expose 24 hours before you know you re sick need protection. Like pregnant women, the elderly, and immune compromised

29 Communicating when Differing Views I might get sick if I get the flu vaccine The flu vaccine does not give you the flu, it prevents it. Nichols VA study showed those who are vaccinated against flu get sick far less during the year from other viruses too Children s of Minnesota Influenza Vaccination Interventions Leadership priority as part of patient and staff safety Pre-season education/marketing to promote vaccination Electronic modes: screen-saver messages, home-page thermometer FluVaxTrax electronic tracking system On-site vaccination clinics for all staff on all shifts Roving vaccination carts to floors Unit Based Vaccinator program for unit-based vaccine on 3 shifts Provided at staff meetings, special language meetings Available throughout the influenza season at Employee Health Clinic Incentives, Recognition: 100% Club, Most Improved Real-time data evaluation and actions during the season focus groups, unit feedback on their rates, etc. Transparent comparison of departments Accountability for non-responders. Letter in their performance file

30 Communicating with HCPs In Summary Who: Credible colleague, trusted family What: Clear, concise facts with trust When: For most, at beginning of season, for the hesitant, when disease risk is higher Where: On their unit, cafeteria, to their inbox How: Directly, regularly, often; flexibly, creatively, with technology and face-to-face With: Facts, stories, science, emotion, transparency, real-time data and a variety of communication strategies

31 Questions & Answers CME Credit/Webinar Evaluation The National Foundation for Infectious Diseases (NFID) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. NFID designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit TM. Online evaluation and post-test will be available following the webinar at: Certificate will be available for print or download following successful completion of online evaluation and post-test 31

32 Upcoming Clinical Vaccinology Courses Spring 2016 Clinical Vaccinology Course March 18-20, 2016 Phoenix, AZ Fall 2016 Clinical Vaccinology Course November 4-6, 2016 Philadelphia, PA Register: Subscribe for future updates: Join us for upcoming NFID CME Webinars The Importance of Pneumococcal Vaccination Wednesday, February 3, :00 PM ET Register: Subscribe for future updates: 32