Transcript Diapositive 1 - Society for Healthcare Epidemiology of

Influenza Media Teleconference
February 14, 2006
*Teleconference sponsored by GlaxoSmithKline
Why We Are Here Today
Facilitate roundtable discussion on the importance
of healthcare worker immunization against influenza
 Overview of influenza virus
 Impact of influenza outbreaks on healthcare setting
 Benefits of influenza vaccination among healthcare workers
How media can help
2
Society for Healthcare Epidemiology of
America (SHEA)
Founded in 1980 to foster the development and
application of the science of healthcare epidemiology
Organization’s mission is to advance the science of
healthcare epidemiology through research and
education and translate knowledge into effective policy
and practice
3
Introductions
Panelists
 Trish Perl, MD, MSc
– President, The Society for Healthcare Epidemiology of America (SHEA)
 Kristin Nichol, MD, MPH
– Professor of Medicine, University of Minnesota; Chief of Medicine &
Director, Primary Care Service Line, Minneapolis VA Medical Center
 Tom Talbot, MD, MPH
– Assistant Professor of Medicine and Preventive Medicine, Associate
Hospital Epidemiologist, Vanderbilt University School of Medicine
 Ken Sands, MD
– Health Care Quality, Beth Israel Deaconess Medical Center, Boston, MA
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Agenda
Overview of influenza virus (Dr. Nichol)
 Complications, epidemiology and prevention
-
Influenza vaccination (Dr. Talbot)
 Economic benefits
 Risks associated with not vaccinating
 Vaccination rates among healthcare workers
Current healthcare worker influenza vaccination
rates (Dr. Sands)
 Impact of healthcare setting outbreaks on healthcare
community and patients
 Benefits of healthcare worker vaccination
5
Kristin Nichol, MD, MPH
Professor of Medicine
University of Minnesota
Chief of Medicine & Director, Primary Care
Service Line
Minneapolis VA Medical Center
6
Influenza Virus
Orthomyxovirus
 Single stranded RNA virus
Segmented
genome
HA
NA
(segmented genome)
- Type A:
- humans, animals, birds,
more severe
- Type B:
- humans only, more
common in children
- Type C:
- uncommon in humans
 2 surface glycoproteins
- Hemagglutinin (HA)
- attachment & entry
- Neuraminidase (NA)
M2 ion channel
protein
Matrix
protein
- release
Influenza A Virus
CDC. Influenza, The Pink Book, 8th ed.
Cox, The Lancet 1999
7
Epidemics, Pandemics and Antigenic
Changes
Influenza viruses cause epidemics & pandemics
 Size & relative impact result of
- Antigenic variation, amount of immunity in populations &
relative virulence
Antigenic variation result of changes in genes
encoding for HA & NA
 Drift – point mutations (both A & B)
- Minor changes, same subtype
- Associated with epidemics
 Shift – genetic reassortment (A)
- Major change, new subtype
- Associated with pandemics
CDC. Influenza, The Pink Book, 8th ed.
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Epidemic Influenza is a Common,
Miserable, and Often Serious Illness
Acute respiratory illness
 Abrupt onset of symptoms
Incidence: 5% to 20% of population
 Higher in children
Serious fatality: 0.5 to 1 per 1000
 Higher in elderly
Spread by coughing and sneezing
CDC: Influenza Fact Sheet.
Glezen, PIDJ, 1997.
9
Transmission of Influenza
* Droplet
* Aerosol
* Direct Contact
Bridges. Clin Infect Dis 2003; 1094.
CDC. Influenza, The Pink Book, 8th ed.
10
Presentation of Clinical Influenza Differs
By Age Group
Sign/Symptom
Children
Adults
Elderly
Cough (nonproductive)
++
++++
+++
Fever
+++
+++
+
Myalgia
+
+
+
Headache
++
++
+
Malaise
+
+
+++
Sore throat
+
++
+
Rhinitis/nasal congestion
++
++
+
Abdominal pain/diarrhea
+
–
+
Nausea/vomiting
++
–
+
++++ Most frequent sign/symptom
+ Least frequent
– Not found
Cox NJ, Subbarao K. Lancet. 1999.
11
Morbidity Associated with
Influenza Episodes
Restricted Activity
10% to 20%
5 – 6 days
10+ days
Bed Disability
3 – 4 days
Absenteeism
3 days
Medically Attended
50%
Kavet J. Am J Public Health 1977.
Treanor, JAMA, 2000.
Nichol, ICHE, 1997.
The MIST Study Group, The Lancet, 1998.
12
Influenza Illness – The Tip of the Iceberg
Influenza Illness
• Exacerbations of
chronic diseases
• Secondary infections
• Other
- Misery
-
Absenteeism
Physician Visits
Antibiotic Use
Hospitalizations
Deaths
CDC. Influenza, The Pink Book, 8th ed.
Monto, Archives of Internal Medicine, 2000.
MMWR 2005.
13
Influence of Influenza Epidemics on
Seasonal Mortality
P&I
Mortality
All Cause
Mortality
Simonsen, Am J Public Health 1997.
14
Average Number of Excess All Cause Deaths
Attributable to Influenza
US, 1990-1991 thru 1998-1999
Age Group Influenza
A(H1N1)
Influenza
A(H3N2)
Influenza
B
Total
<1
0
3
85
88
1-4
34
103
38
175
5 - 49
501
1,685
383
2,569
50 - 64
348
3,360
684
4,392
65+
1,954
34,866
7,159
43,979
Totals
2,837
40,017
8,349
51,203
Thompson, JAMA. 2003.
15
Influenza-Associated Deaths are Similar to
Other Important Causes of Deaths in Adults
Influenza
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
VPD's Adults
Colorectal CA
Breast CA
Prostate CA
Suicide
Parkinson's
Range of
VPD deaths
in adults
HIV
VPD's Kids
Adapted from: CDC, NCHS (online data for 2000); CDC Summary of Notifiable Diseases, US 2003; MMWR 52 (54) Apr 22, 2005 for 2003;
CDC NVSS, Deaths: Final Data for 2000; 2002; 50 (15).
Thompson, JAMA 2003.
16
Epidemic Influenza Continues to Have a
Huge Annual Impact
Estimates for the U.S.
Cases:
Days of illness:
Work & school loss:
Hospitalizations:
Deaths:
Costs:
25 – 50+ million cases
100 – 200 million days
Tens of millions
85,000 – 550,000+
34,000* – 51,000**
Billions of dollars
+ Ave respiratory & circulatory = 294,000 1979-80 thru 2000-01
* Ave all cause, 1976-77 thru 1998-99.
**Ave all cause 1990-91 thru 1998-99.
Thompson, JAMA 2003.
Thompson, JAMA 2004.
CDC, Influenza, The Pink Book, 8th ed.
Pleis, American College of Physicians, 2002.
17
Options for Preventing & Controlling
Influenza
Hand hygiene
Respiratory hygiene / cough etiquette
Contact avoidance
Antivirals
Immunization
CDC. Preventing the Flu 2006.
18
Tom Talbot, MD, MPH
Assistant Professor of Medicine and
Preventive Medicine, Associate Hospital
Epidemiologist
Vanderbilt University School of
Medicine, Nashville, TN
19
Influenza Vaccines
Types of influenza vaccines:
 Inactivated (1968)
 Live attenuated (2003)
Trivalent (covers 3 circulating strains)
Usually available in October annually
Work by stimulating antibody formation against viral
surface proteins
Redosed annually because circulating virus may alter
these proteins
CDC. Influenza, The Pink Book, 8th ed.
MMWR 2005.
CDC Influenza Fact Sheet 2005.
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Comparison of Influenza Vaccines
Route
Type
Frequency
Approved Ages
Side effects
MMWR 2005.
Live Attenuated
Inactivated
Intranasal
Live
IM
Killed
Annual
Healthy,
5 – 49 years
Runny nose,
sore throat
Annual
≥ 6 months
Sore arm,
arm swelling
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Cost/Benefit for Vaccination
of Healthy Adults
Vaccination of healthy adults leads to
 13%–44% reduction in healthcare–provider visits
 18%–45% reduction in lost workdays
 18%–28% reduction in days working with reduced
effectiveness
 25% reduction in antibiotic use for influenza-associated
illnesses
Average annual savings of $13.66 per person
vaccinated
MMWR 2005.
22
ACIP Target Groups
for Influenza Vaccination
Groups at increased risk for influenza-related
complications






Persons ≥ 50 years old
Residents of chronic care facilities
Persons with chronic medical disorders
Children/adults on long-term aspirin therapy
Children ages 6 to 23 months old
Women who will be pregnant during the influenza
season
MMWR 2005.
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ACIP Target Groups
for Influenza Vaccination
Groups that can transmit influenza to
high-risk persons
 Employees of chronic care facilities
 Home care providers
 Household contacts (including children) of
high-risk persons
 Healthcare workers (HCWs)
MMWR 2005.
24
Why is Healthcare Worker Influenza
Vaccination Important?
HCWs have frequent contact with patients at
high-risk for influenza infection and its
complications
HCWs can serve as a vehicle for spread of flu
HCW absenteeism can stress health system
in times of community epidemics
MMWR 2005.
Talbot, ICHE 2005.
25
Impact of HCW Influenza Vaccination
Influenza
Infection
Sick Days Due
to Respiratory Days Lost from
Infection
Work
Patient
Mortality
Patient
Mortality
0
Percent Reduction
10
20
30
28
40
41
50
41
39
60
70
80
90
88
100
Talbot, ICHE 2005; Feery, JID 1979; Saxen, PIDJ 1999; Wilde, JAMA 1999; Carman, Lancet 2000; Potter, JID 1997.
26
HCW Vaccination & the Impact Upon
Patient Mortality
HCW Vaccinated
HCW Not Vaccinated
25
22.4
Patient Mortality (%)
20
17
15
13.6
10
10
5
0
Potter J JID 1997;175:1
Carman WF Lancet 2000;355:93
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Healthcare-Associated Influenza
Outbreaks reported in most care areas
HCW = culprit source
Influenza infection causes minimal or no symptoms in up
to 25% of cases
Such workers still shed (and spread) virus
76.6% HCW work while ill with influenza like illness
Worked mean 2.5 days while ill with influenza like illness
CDC. Influenza, The Pink Book, 8th ed.
MMWR 2005.
Stott, Occup. Med. 2002.
Talbot, ICHE 2005.
Elder, BMJ 1996.
Lester, ICHE 2003.
28
Healthcare-Associated Influenza
Cases likely undetected because
 Few cases for each exposure not noted as
outbreak
 Inpatients not tested for influenza
 Shorter length of stay leads to discharge before
symptom onset
29
Not Setting a Good Example
2003: Only 40% of health-care workers were
vaccinated
Talbot, ICHE 2005.
MMWR 2005.
30
Location of Healthcare-Associated
Outbreaks of Influenza
Neonatal ICUs
Pediatric wards
Adult transplant units
Pediatric transplant units
Infectious disease units
General medical wards
Geriatric wards
Long-term care
facilities
Oncology units
Pulmonary
rehabilitation centers
Emergency
departments
Talbot, ICHE 2005.
Stott, Occup. Med 2002.
31
Ken Sands, MD
Health Care Quality
Beth Israel Deaconess Medical Center,
Boston, MA
32
The Healthcare Facility Experiencing
an Influenza Outbreak
Can anticipate that the outbreak will last anywhere
from a few days to months
Can expect 10-60% of HCWs to contract influenza
Can expect increased HCW absenteeism
May see attributable morbidity and death
Can anticipate additional patient care costs that
outweigh the costs of a HCW vaccination program
Nichol, NEJM 1995.
Salgado, The Lancet 2002.
33
Illustrative Case: Mortality Influenza Outbreak
in a Neonatal Intensive Care Unit
34 bed NICU in Hamilton, Ontario
Epidemic of Influenza A, January-May 1998
19 infants infected; one death
Vaccination rate among staff: 15%
Initial vector thought to be either a staff
member or a visitor
Cunney, ICHE 2000.
34
Illustrative Case: HCW Role Influenza Outbreak
in an Organ Transplant Unit
12 Bed Transplantation unit in France
Over 4 days in January 2000, 4 confirmed
patient cases
Only 1 of 4 patient cases had been visited by
a non-HCW during the incubation period
3 HCWs (11% of unit staff) with clinical
diagnosis of influenza
Malavaud, Transplatation 2001.
35
Illustrative Case Report: HCW Attack Rates
Influenza Outbreak in an Infectious Disease Unit
23 bed AIDS/ID ward in
Spain
Outbreak during a 16day period in February
2001
No community-based
influenza activity at this
same time
Influenza Attack Rate
60%
50%
40%
30%
20%
10%
0%
Patients
Clinical Dx
HCWs
Laboratory Diagnosis
Horcajada. Eur Respir J 2003.
36
The Facility With a Strong Employee
Vaccination Program
Is following a CDC recommendation for HCWs
first established in 1981
Based on studies of the general population, can
anticipate lower absenteeism, less staff
disruption, and lower health care consumption
among its employees
May decrease patient mortality by as much as
40% (based on studies in the long-term care
setting)
Poland, Vaccine 2005.
Nichol, NEJM 1995.
37
Effectiveness of Influenza Vaccine in
Healthcare Professionals
Two Baltimore Hospitals
in early 1990s
264 HCWs
(mostly residents)
Random assignment to
flu vaccine or controls
30%
25%
Vaccinated
Control
20%
15%
10%
5%
0%
Wilde, JAMA 1999.
Confirmed Flu Missed Work
38
Mortality Benefit Demonstrated
in Long-Term Care
20 LTC facilities
in the UK
randomized to
HCW vaccination
or control
5%
Vaccinated
HCWs
51%
22%
Mortality
14%
Control
Virus
positive at
death
6%
Vaccination
Hospital
0%
0%
20%
40%
60%
Carman, The Lancet 2000.
39
Reported Reasons for
Low HCW Vaccination Rates
Reason
Inconvenient/Too busy/Forgot
% (Range)
15-83
Concerned for vaccine adverse events
Perception of low risk for influenza
Cost
27-66
15-23
1-5
Fear of needles/Vaccine-averse
Vaccine not effective
8-18
8-24
Egg allergy
1-7
Heimberger, ICHE 1995; Lester, ICHE 2003; Martinello, ICHE 2003; Nichol, ICHE 1997; Steiner, ICHE 2002; Weingarten, AJIC 1989.
40
“I don’t want to catch the flu from a shot.”
Widely held belief (still)
Not supported by randomized clinical trials
Placebo Group
Vaccine Group
Fever
6.1%
6.2%
Tiredness
19.4 %
18.9%
Feeling “under
17.5 %
16.0%
the weather”
Muscle aches
5.7%
6.2%
Headaches
14.4%
10.8%
Arm soreness
24.1%
63.8%
Nichol, NEJM 1995.
CDC Influenza Q&A: Flu Shot.
41
Methods to Improve
HCW Vaccination Rates
Strong and visible administrative leadership
Visible vaccination of key leaders
Vaccination champions
Provision of adequate staff and resources
Off-hours clinics
Use of mobile vaccination carts
Vaccination at staff/departmental meetings
Train the trainer programs that empower unit staff
42
Methods to Improve
HCW Vaccination Rates
Provision of vaccine free of charge
Targeted education

Incl. dispelling of vaccine myths
Active declination for HCWs
Tracking of individual & unit-based HCW vaccination
compliance
Surveillance for healthcare-associated influenza
43
Can these Interventions
Have an Effect?
HCW Vaccination Rates in Selected Institutions
Vaccination Rate (%)
120%
96%
100%
80%
67%
60%
40%
40%
20%
4%
0%
NFID 2005.
Salgado, The Lancet 2002.
Virginia Mason Hospital Website.
U Virginia 1988 U Virginia 2000 Virginia Mason
Current
National Norm
44
Larger Impact on Healthcare System
Decreased absenteeism means a more
stable, more reliable workforce
Secondary impact of improved work
conditions on patient safety
45
In Summary
HCW vaccination is an imperative on either a
clinical, economic, and ethical basis
The challenge is not whether to vaccinate,
but how to ensure compliance
46
Striving for Universal HCW Vaccination
Thought Leaders have taken this position in
the academic literature
Virginia Mason Hospital: Instituted a
vaccination requirement
As of 2005, seven states have enacted
influenza vaccination mandates for
healthcare workers in long-term care (with a
few having mandates in acute care)
Lester, ICHE 2003.
APIC Website.
Virginia Mason Hospital Website.
Poland, Vaccine 2005.
47
Closing Remarks
48
Q&A Session
49