Influenza Media TeleconferenceFebruary 14, 2006

*Teleconference sponsored by GlaxoSmithKline

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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

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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

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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

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• 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

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Kristin Nichol, MD, MPHProfessor of Medicine

University of MinnesotaChief of Medicine & Director, Primary Care

Service LineMinneapolis VA Medical Center

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Orthomyxovirus Single stranded RNA virus

(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)- release

HA

NA

Segmentedgenome

MatrixproteinM2 ion channel

protein

Influenza A Virus

Influenza Virus

CDC. Influenza, The Pink Book, 8th ed.Cox, The Lancet 1999

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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

Epidemics, Pandemics and Antigenic Changes

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.

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* Droplet* Aerosol* Direct Contact

Transmission of Influenza

Bridges. Clin Infect Dis 2003; 1094.CDC. Influenza, The Pink Book, 8th ed.

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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.

Presentation of Clinical Influenza Differs By Age Group

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Restricted Activity

10% to 20%

5 – 6 days10+ 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.

Morbidity Associated with Influenza Episodes

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Influenza Illness

• Exacerbations of chronic diseases• Secondary infections• Other

- Misery- Absenteeism- Physician Visits- Antibiotic Use- Hospitalizations- Deaths

Influenza Illness – The Tip of the Iceberg

CDC. Influenza, The Pink Book, 8th ed.Monto, Archives of Internal Medicine, 2000.MMWR 2005.

14Simonsen, Am J Public Health 1997.

P & IP & IMortalityMortality

All CauseAll CauseMortalityMortality

Influence of Influenza Epidemics on Seasonal Mortality

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Age Group Influenza A(H1N1)

InfluenzaA(H3N2)

InfluenzaB

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.

Average Number of Excess All Cause Deaths Attributable to Influenza

US, 1990-1991 thru 1998-1999

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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

HIV

VPD's Kids

Range of VPD

deaths in adults

Influenza

Influenza-Associated Deaths are Similar to Other Important Causes of Deaths in Adults

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.

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Cases: 25 – 50+ million cases

Days of illness: 100 – 200 million days

Work & school loss:Tens of millions

Hospitalizations: 85,000 – 550,000+

Deaths: 34,000* – 51,000**

Costs: Billions of dollars

Estimates for the U.S.

+ 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.

Epidemic Influenza Continues to Have a Huge Annual Impact

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Hand hygiene

Respiratory hygiene / cough etiquette

Contact avoidance

Antivirals

Immunization

Options for Preventing & Controlling Influenza

CDC. Preventing the Flu 2006.

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Tom Talbot, MD, MPHAssistant Professor of Medicine and

Preventive Medicine, Associate Hospital Epidemiologist

Vanderbilt University School of Medicine, Nashville, TN

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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

Influenza Vaccines

CDC. Influenza, The Pink Book, 8th ed.MMWR 2005.CDC Influenza Fact Sheet 2005.

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Live Attenuated Inactivated

Route Intranasal IM

Type Live Killed

Frequency Annual Annual

Approved AgesHealthy,

5 – 49 years≥ 6 months

Side effects Runny nose, sore throat

Sore arm, arm swelling

Comparison of Influenza Vaccines

MMWR 2005.

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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

Cost/Benefit for Vaccination of Healthy Adults

MMWR 2005.

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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

ACIP Target Groups for Influenza Vaccination

MMWR 2005.

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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)

ACIP Target Groups for Influenza Vaccination

MMWR 2005.

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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

Why is Healthcare Worker Influenza Vaccination Important?

MMWR 2005.Talbot, ICHE 2005.

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88

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41 41 39

0

10

20

30

40

50

60

70

80

90

100

InfluenzaInfection

Sick Days Dueto Respiratory

InfectionDays Lost from

WorkPatient

MortalityPatient

Mortality

Percent Reduction

Impact of HCW Influenza Vaccination

Talbot, ICHE 2005; Feery, JID 1979; Saxen, PIDJ 1999; Wilde, JAMA 1999; Carman, Lancet 2000; Potter, JID 1997.

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10

13.6

17

22.4

0

5

10

15

20

25

Potter J JID 1997;175:1 Carman WF Lancet 2000;355:93

HCW Vaccinated HCW Not Vaccinated

Patient Mortality (%)

HCW Vaccination & the Impact Upon Patient Mortality

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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

Healthcare-Associated Influenza

CDC. Influenza, The Pink Book, 8th ed.MMWR 2005.Stott, Occup. Med. 2002.Talbot, ICHE 2005.Elder, BMJ 1996.Lester, ICHE 2003.

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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

Healthcare-Associated Influenza

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2003: Only 40% of health-care workers were vaccinated

Not Setting a Good Example

Talbot, ICHE 2005.

MMWR 2005.

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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.

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Ken Sands, MDHealth Care Quality

Beth Israel Deaconess Medical Center, Boston, MA

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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

The Healthcare Facility Experiencing an Influenza Outbreak

Nichol, NEJM 1995.Salgado, The Lancet 2002.

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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

Illustrative Case: Mortality Influenza Outbreak in a Neonatal Intensive Care Unit

Cunney, ICHE 2000.

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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

Illustrative Case: HCW Role Influenza Outbreak in an Organ Transplant Unit

Malavaud, Transplatation 2001.

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23 bed AIDS/ID ward in Spain

Outbreak during a 16-day period in February 2001

No community-based influenza activity at this same time

Illustrative Case Report: HCW Attack RatesInfluenza Outbreak in an Infectious Disease Unit

Influenza Attack Rate

0%

10%

20%

30%

40%

50%

60%

Patients HCWs

Clinical Dx Laboratory Diagnosis

Horcajada. Eur Respir J 2003.

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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)

The Facility With a Strong Employee Vaccination Program

Poland, Vaccine 2005.Nichol, NEJM 1995.

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Two Baltimore Hospitals in early 1990s264 HCWs (mostly residents)Random assignment to flu vaccine or controls

0%

5%

10%

15%

20%

25%

30%

Confirmed Flu Missed Work

VaccinatedControl

Effectiveness of Influenza Vaccine in Healthcare Professionals

Wilde, JAMA 1999.

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20 LTC facilities in the UK randomized to HCW vaccination or control

0%

14%

51%

6%

22%

5%

0% 20% 40% 60%

Viruspositive at

death

Mortality

VaccinatedHCWs

Control

VaccinationHospital

Carman, The Lancet 2000.

Mortality Benefit Demonstrated in Long-Term Care

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Reason % (Range)

Inconvenient/Too busy/Forgot 15-83

Concerned for vaccine adverse events 27-66

Perception of low risk for influenza 15-23

Cost 1-5

Fear of needles/Vaccine-averse 8-18

Vaccine not effective 8-24

Egg allergy 1-7

Reported Reasons for Low HCW Vaccination Rates

Heimberger, ICHE 1995; Lester, ICHE 2003; Martinello, ICHE 2003; Nichol, ICHE 1997; Steiner, ICHE 2002; Weingarten, AJIC 1989.

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Widely held belief (still)

Not supported by randomized clinical trialsPlacebo Group Vaccine Group

Fever 6.1% 6.2%

Tiredness 19.4 % 18.9%

Feeling “under the weather”

17.5 % 16.0%

Muscle aches 5.7% 6.2%

Headaches 14.4% 10.8%

Arm soreness 24.1% 63.8%

“I don’t want to catch the flu from a shot.”

Nichol, NEJM 1995.

CDC Influenza Q&A: Flu Shot.

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Strong and visible administrative leadership Visible vaccination of key leadersVaccination championsProvision of adequate staff and resources Off-hours clinicsUse of mobile vaccination cartsVaccination at staff/departmental meetingsTrain the trainer programs that empower unit staff

Methods to Improve HCW Vaccination Rates

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Provision of vaccine free of charge  Targeted education Incl. dispelling of vaccine myths

Active declination for HCWs Tracking of individual & unit-based HCW vaccination complianceSurveillance for healthcare-associated influenza

Methods to Improve HCW Vaccination Rates

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HCW Vaccination Rates in Selected Institutions

4%

96%

40%

67%

0%

20%

40%

60%

80%

100%

120%

U Virginia 1988 U Virginia 2000 Virginia Mason CurrentNational Norm

Vaccination Rate (%)

Can these Interventions Have an Effect?

NFID 2005.Salgado, The Lancet 2002.Virginia Mason Hospital Website.

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Decreased absenteeism means a more stable, more reliable workforce

Secondary impact of improved work conditions on patient safety

Larger Impact on Healthcare System

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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

In Summary

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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)

Striving for Universal HCW Vaccination

Lester, ICHE 2003.APIC Website.Virginia Mason Hospital Website.Poland, Vaccine 2005.

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Closing Remarks

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Q&A Session