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Public Health Special Edition

Enough is Enough

Improving Influenza Vaccination Rates among Healthcare workers By

Owen Simwale, PhD. MPH – Pennsylvania Department of Health, Harrisburg, PA Stephen Ostroff, MD – Pennsylvania Department of Health, Harrisburg, PA William R. Sonnenberg, MD, FAAFP - Titusville Area Hospital, Titusville, PA President-Elect, Pennsylvania Academy of Family Physicians

Every winter, influenza (the flu) causes a substantial burden of illness in Pennsylvania, accounting for 1-5% of all outpatient visits, numerous hospitalizations, hundreds to thousands of deaths, and enormous healthcare expenditures (hcp). Focusing only on lab-confirmed reports, during the 2010/11 flu season over 18, 000 cases were reported to the Pennsylvania Department of Health (PADOH), involving 1, 527 hospitalizations and 90 deaths, A total of 179 flu outbreaks in 158 long term care facilities (LTCF) were also reported last flu season1,2. Although the past flu season (2011/12) was very mild compared to previous seasons, influenza remains a high-priority public health concern because (a) it is one of the principal causes of infectious disease-related morbidity and mortality (b) it is highly unpredictable in terms of incidence and severity from year to year (c)

it produces periodic pandemics such as pH1N1 in 2009, and (d) treatment and annual prevention activities are resource-intensive. Primary care physicians (PCP) are an important piece of the jigsaw puzzle that constitutes influenza. Patients are more likely to get vaccination if they are advised to do so or reminded by their PCP. PCPs administer much of Pennsylvania’s annual supply of vaccine. They also form a high-risk group for influenza infection and can transmit the virus to their co-workers, their families, and their patients. In one study, influenza vaccination of healthcare workers (hcw) showed an 88% decrease in influenza infections among employees and a 28% decrease in flu-related absenteeisms7-11. Routine vaccination of hcw’s has also been associated with reductions (39% to 41%) in total patient mortality10-12.

There is a great deal of evidence showing illness among unvaccinated Health Care Workers (HCWs) may contribute to influenza outbreaks in both acute and long term care settings4. An assessment of nursing home outbreaks in Pennsylvania during the 2007/08 influenza season showed that among 92 flu outbreaks in 91 LTCFs, a majority of outbreaks and hospitalizations occurred in facilities where less than 60% of employees were vaccinated and in facilities with ill employees1, 2. Vaccination is the single most effective measure to prevent influenza. Vaccination of HCWs reduces influenza infection and employee absenteeism, prevents mortality in their patients, and results in cost savings to sponsoring health institutions4-6. In spite of the clear benefits of HCW vaccination, shamefully almost half (40-50%)

1 | Pennsylvania Academy of Family Physicians Foundation

of HCWs still do not get a flu shot every year6-8. Decades of encouraging HCWs to voluntarily receive flu vaccination has yielded only marginal gains in vaccine uptake. Most healthcare facilities have reached a plateau at or below the 60% mark7,8.

be recognized by the state with a certificate of excellence and inducted into the patient safety and employee health honor roll. Cases studies of hospitals and long term care facilities that have achieved near universal coverage can be found at, www. and at http://www.haponline. org/quality/resources/flu-campaign/.

The Healthy People 2020 goal for influenza vaccination among HCWs is 90%. Therefore we have a long way to go to attain that sort of coverage. At present, PADOH is only aware of 40 hospitals (of about 250 licensed) and 12 LCTFs (out of over 700) that have attained a 90% or greater vaccination rate among their healthcare workforce.

Given the overwhelming benefit of healthcare worker vaccination, the status quo with HCW vaccination rates in Pennsylvania cannot go unchallenged. Enough is enough and our current approaches are unlikely to produce meaningful changes in coverage. Therefore, PADOH encourages all facilities in the Commonwealth to reexamine their current policies and make the pledge to achieve universal vaccination of their workforce to keep their workers safe and healthy. And we all owe it to our patients to keep them as safe and healthy as possible.

Evidence to date shows the only way to achieve near universal vaccine coverage of HCWs is to implement mandatory programs (influenza vaccination as a condition of employment) at the institutional level6. Therefore, the Pennsylvania Department of Health, has joined a growing list of health care organizations that support and promote mandatory influenza vaccinations policies for HCWs. This flu season (2011/12), PADOH has joined into a partnership with the Hospital and Health System Association of Pennsylvania (HAP), the Pennsylvania Immunization Coalition and the Center for Vaccine Ethics at the University of Pennsylvania to actively encourage implementation of mandatory influenza vaccination at the institutional level. Healthcare facilities that vaccinate over 90 percent of staff will

Corresponding author: | 2

References 1. Pennsylvania Department of Health, 2010/11 flu surveillance data (unpublished). 2. Smith E., Simwale O., Ostroff, S. (2010). Outbreaks of Influenza in long term care facilities and influenza vaccination. Abstract, presented at the 2010 American Public Health Association Annual Conference. Accessed on 10/18/2011 from, 3. Flood EM and others. (2011). Parents’ decision-making regarding vaccinating their children against influenza: A web-based survey. Clinical Therapeutics. 2010 August; 32(8):1448-67. 4. Horcajada JP, Pumarola T, Martinez JA. (2003). A nosocomial outbreak of influenza during a period without influenza epidemic activity. Eur Respir J 2003; 21(2):303-307. 5. Centers for Disease Control and Prevention (CDC). Place of influenza vaccination among adults --United States, 2010-11 influenza season. MMWR Morb Mortal Wkly Rep. 2011 Jun 17; 60(23):781-5. Accessed on 11/10/11 from, Disease%20Control%20and%20Prevention%20(CDC)%22%5BCorporate%20Author%5D 6. Katherine M. Harris and others. (2011). Influenza Vaccination Coverage among Health-Care Personnel --- United States, 2010--11 Influenza Season. Morbidity and Mortality Weekly Report (MMWR). August 19, 2011 / 60(32); 1073-1077. Accessed on 10/11/11from mmwrhtml/mm6032a1.htm?s_cid=mm6032a1_w 7. Belshe RB, Edwards KM, Vesikari T, Black SV, Walker RE, Hultquist M, Kemble G, Connor EM; CAIV-T Comparative Efficacy Study Group. Live attenuated versus inactivated influenza vaccine in infants and young children. N Engl J Med. 2007;356(7):685-96 8. Beran J, Vesikari T, Wertzova V, Karvonen A, Honegr K, Lindblad N, Van Belle P, Peeters M, Innis BL, Devaster JM. Efficacy of inactivated split-virus influenza vaccine against culture-confirmed influenza in healthy adults: a prospective, randomized, placebo-controlled trial. J Infect Dis 2009;200(12):1861-9. 9. Slinger R, Dennis P. Nosocomial influenza at a Canadian pediatric hospital from 1995 to 1999: opportunities for prevention. Infect Control, Hosp Epidemiol2002;23:627-629. 10. Talbot et al (2005). Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages in SHEA Position Paper,HCW_Flu_SHEA_Position_Paper.pdf, Accessed on July 12, 2011. 11. Wenzel RP, Deal EC, Hendley JO. Hospital-acquired viral respiratory illness on a pediatric ward. Pediatrics 1977;60:367-371. 12. Centers for Disease Control and Prevention. (2010). Interim results: state-specific influenza A (H1N1) 2009 monovalent vaccination coverage - United States, October 2009-January 2010. MMWR. Morbidity and mortality weekly report, 59(12), 363-8. Retrieved from pubmed/20360670 | 3

Enough is Enough - Improving HCW Flu Vaccine Rates