Public Health

Every winter, influenza (the flu) causes a substantial burden of illness in Pennsylvania, account-ing for 1-5% of all outpatient visits, numerous hospitalizations, hun-dreds to thousands of deaths, and enormous healthcare expenditures (hcp). Focusing only on lab-con-firmed reports, during the 2010/11 flu season over 18, 000 cases were reported to the Pennsylvania Department of Health (PADOH), in-volving 1, 527 hospitalizations and 90 deaths, A total of 179 flu out-breaks in 158 long term care facili-ties (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 mor-bidity 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 vac-cination 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 trans-mit 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 absen-teeisms7-11. 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 unvaccinat-ed Health Care Workers (HCWs) may contribute to influenza out-breaks in both acute and long term care settings4. An assessment of nursing home outbreaks in Penn-sylvania during the 2007/08 influ-enza season showed that among 92 flu outbreaks in 91 LTCFs, a majority of outbreaks and hospital-izations occurred in facilities where less than 60% of employees were vaccinated and in facilities with ill employees1, 2. Vaccination is the single most ef-fective measure to prevent influen-za. Vaccination of HCWs reduces influenza infection and employee absenteeism, prevents mortal-ity 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%)

of HCWs still do not get a flu shot every year6-8. Decades of encour-aging 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. 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. Evidence to date shows the only way to achieve near universal vaccine coverage of HCWs is to implement mandatory programs (influenza vaccination as a condi-tion of employment) at the institu-tional level6. Therefore, the Penn-sylvania 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 Co-alition and the Center for Vaccine Ethics at the University of Pennsyl-vania to actively encourage imple-mentation of mandatory influenza vaccination at the institutional level. Healthcare facilities that vaccinate over 90 percent of staff will

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.pahcwfluvax.org, www.flufreepa.com and at http://www.haponline.org/quality/resources/flu-campaign/. 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 cur-rent approaches are unlikely to produce mean-ingful 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.

Corresponding author: owsimwale@pa.gov

Enough is Enough Improving Influenza Vaccination Rates among Healthcare workers

www.pafp.com | 21 | Pennsylvania Academy of Family Physicians Foundation

Special Edition

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, PAPresident-Elect, Pennsylvania Academy of Family Physicians

By

www.pafp.com | 3

References

1. PennsylvaniaDepartmentofHealth,2010/11flusurveillancedata(unpublished).

2. SmithE.,SimwaleO.,Ostroff,S.(2010).OutbreaksofInfluenzainlongtermcarefacilitiesandinfluenzavaccination.Abstract,presentedatthe2010AmericanPublicHealthAssociationAnnualConference.Accessedon10/18/2011from,http://www.cste.org/webpdfs/ac/abstractbook2011.pdf

3. FloodEMandothers.(2011).Parents’decision-makingregardingvaccinatingtheirchildrenagainstinfluenza:Aweb-basedsurvey.ClinicalTherapeutics.2010August;32(8):1448-67.

4. HorcajadaJP,PumarolaT,MartinezJA.(2003).Anosocomialoutbreakofinfluenzaduringaperiodwithoutinfluenzaepidemicactivity.EurRespirJ2003;21(2):303-307.

5. CentersforDiseaseControlandPrevention(CDC).Placeofinfluenzavaccinationamongadults---UnitedStates,2010-11influenzaseason.MMWRMorbMortalWklyRep.2011Jun17;60(23):781-5.Accessedon11/10/11from,http://www.ncbi.nlm.nih.gov/pubmed?term=%22Centers%20for%20Disease%20Control%20and%20Prevention%20(CDC)%22%5BCorporate%20Author%5D

6. KatherineM.Harrisandothers.(2011).InfluenzaVaccinationCoverageamongHealth-CarePersonnel---UnitedStates,2010--11InfluenzaSeason.MorbidityandMortalityWeeklyReport(MMWR).August19,2011/60(32);1073-1077.Accessedon10/11/11fromhttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6032a1.htm?s_cid=mm6032a1_w

7. BelsheRB,EdwardsKM,VesikariT,BlackSV,WalkerRE,HultquistM,KembleG,ConnorEM;CAIV-TComparativeEfficacyStudyGroup.Liveattenuatedversusinactivatedinfluenzavaccineininfantsandyoungchildren.NEnglJMed.2007;356(7):685-96

8. BeranJ,VesikariT,WertzovaV,KarvonenA,HonegrK,LindbladN,VanBelleP,PeetersM,InnisBL,DevasterJM.Efficacyofinactivatedsplit-virusinfluenzavaccineagainstculture-confirmedinfluenzainhealthyadults:aprospective,randomized,placebo-controlledtrial.JInfectDis2009;200(12):1861-9.

9. SlingerR,DennisP.NosocomialinfluenzaataCanadianpediatrichospitalfrom1995to1999:opportunitiesforprevention.InfectControl,HospEpidemiol2002;23:627-629.

10. Talbotetal(2005).InfluenzaVaccinationofHealthcareWorkersandVaccineAllocationforHealthcareWorkersDuringVaccineShortagesinSHEAPositionPaper,HCW_Flu_SHEA_Position_Paper.pdf,AccessedonJuly12,2011.

11. WenzelRP,DealEC,HendleyJO.Hospital-acquiredviralrespiratoryillnessonapediatricward.Pediatrics1977;60:367-371.

12. CentersforDiseaseControlandPrevention.(2010).Interimresults:state-specificinfluenzaA(H1N1)2009monovalentvaccinationcoverage-UnitedStates,October2009-January2010.MMWR.Morbidityandmortalityweeklyreport,59(12),363-8.Retrievedfromhttp://www.ncbi.nlm.nih.gov/pubmed/20360670