FOCUS ON INFECTION PREVENTION Update: Are Influenza, Pneumonia, and Vaccination Rates Improving in Nursing Home Residents? Sharon M. Bradley, RN, CIC INFLUENZA AND PNEUMOCOCCAL VACCINATION DATA Senior Infection Prevention Analyst Pennsylvania Patient Safety Authority Since 2006, pneumonia and influenza combined have remained the seventh leading cause of death in people over 65 years of age in the United States.1 Lower respiratory tract infections (LRTIs), including pneumonia and influenzalike illness, are the second most common healthcare-associated infections (HAIs) in Pennsylvania nursing homes.2 Analysis of HAI events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) shows that influenzalike illness rates of infection have remained at 0.00 to 0.01 per 1,000 resident-days over the 2010 to 2012 reporting periods.2 LRTIs, including pneumonia, have shown a slight decrease in infection rate from 0.44 in 2010 to 0.42 in 2012.2 See Table 1. Influenza vaccination has been shown to reduce the risk of influenza and absenteeism in vaccinated adults. Vaccination of both residents and their contacts (e.g., visitors, clinicians) is the foundation of efforts to prevent influenza transmission. Healthcare worker vaccination in particular has been shown to reduce the risk of respiratory ill- ness and death in nursing home residents.3 A previous Pennsylvania Patient Safety Advisory article, “Increasing Influenza and Pneu- monia Vaccination Rates in Long-Term Care,” reported that in 2007, influenza and pneumococcal vaccination rates for Pennsylvania nursing home residents were 3% below the “all-state average.”4 The influenza vaccination rate in Pennsylvania in 2007 was 85.9%.5 Nursing homes in the commonwealth improved on this rate in 2008 and 2009, achieving influenza vaccination rates of 87.3% and 88.1%, respectively.6,7 The pneumococcal vaccination rate in Pennsylvania in 2007 was 83.6 %.5 Nursing homes in the commonwealth improved on this rate in 2008 and 2009, achieving pneumococ- cal vaccination rates of 86.5% and 86.1%, respectively.6,7 However, due to concurrent improvement in nursing homes across the country, the available 2009 vaccination data from the US Department of Health and Human Services’ (HHS) Agency for Health- care Research and Quality shows that performance ratings of Pennsylvania nursing homes remained 3.0% below the all-state average of 91.1% for influenza vaccinations and 2.5% below the all-state average of 88.6% for pneumococcal vaccination.7 HEALTHCARE WORKER VACCINATION TRENDS The overall national healthcare worker influenza vaccination rates have steadily increased over the last decade. Until the 2009-2010 season, less than 50% of US healthcare workers were vaccinated against influenza.8 A Centers for Disease Control and Prevention (CDC) Internet panel survey of 1,944 self-selected healthcare work- ers in April 2013 found that 72.0% of all US healthcare workers reported that they had received an influenza vaccination for the 2012-2013 season. For the same sea- son, 83.1% of healthcare workers in US hospitals received an influenza vaccination, whereas vaccination coverage was only 58.9% for healthcare workers in US long-term care facilities.9 Among all occupational settings surveyed, vaccination was lowest among healthcare workers at US long-term care facilities in the 2011-2012 and 2012-2013 sea- sons. See Table 2. A report from the Pennsylvania Health Care Worker Flu Immunization Campaign shows that the rate of influenza vaccination in Pennsylvania nursing home healthcare workers is less than 60%,10 far below the Healthy People 2020 target of 90%.11 This disparity may be a factor in the lack of improvement in the rate of influenzalike illness reported to PA-PSRS from Pennsylvania nursing homes. Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 137 ©2013 Pennsylvania Patient Safety Authority FOCUS ON INFECTION PREVENTION CDC reports 96.5% coverage among US following risk reduction strategies out- of experts—including the Hospital and healthcare workers who had an employer lined in the Advisory articles “Increasing Healthsystem Association of Pennsylvania requirement for vaccination.9 In the Influenza and Pneumonia Vaccination (HAP), the Authority, the Pennsylvania absence of requirements, increased vac- Rates in Long-Term Care” and “Strate- Immunization Coalition, and Pennsylva- cination coverage was associated with gies to Improve Outcomes in Nursing nia hospitals and health systems that have employers offering vaccination on-site, Home Residents with Modifiable Risk achieved nearly universal vaccination cov- free of charge, and on multiple days.9 Factors for Respiratory Tract Infections,” erage—to brainstorm how best to improve including strategies to increase vaccine vaccine uptake among healthcare workers STRATEGIES FOR IMPROVING availability and acceptance.3,4 The articles in Pennsylvania. The task force held semi- VACCINE UPTAKE are available on the Authority’s website at nars in May and June 2013 to showcase http://patientsafetyauthority.org. best practices and resources for improving Nursing homes may improve their staff The Pennsylvania Department of Health influenza vaccination among healthcare and resident vaccination rates and brought together a voluntary association personnel and will be working with decrease LRTIs in their residents by Table 1. Nursing Home Respiratory Tract Infection Pooled Mean Rates, as Reported to the Pennsylvania Patient Safety Authority, 2009 to 2012 YEAR LOWER RESPIRATORY TRACT INFLUENZALIKE ILLNESSES OVERALL RESPIRATORY TRACT INFECTIONS (I.E., PNEUMONIA, INFECTIONS* BRONCHITIS, TRACHEOBRONCHITIS) No. of Pooled Infection No. of Pooled Infection No. of Pooled Infection Nursing Rate† (95% CI) Nursing Rate† (95% CI) Nursing Rate† (95% CI) Homes Homes Homes Reporting Reporting Reporting 2009‡ NA 0.45 (0.44 to 0.46) NA 0.01 (0.01 to 0.01) NA 0.46 (0.44 to 0.47) 2010 484 0.44 (0.43 to 0.45) 42 0.00 (0.00 to 0.01) 484 0.44 (0.43 to 0.45) 2011 562 0.43 (0.42 to 0.44) 121 0.01 (0.01 to 0.01) 565 0.44 (0.43 to 0.45) 2012 492 0.42 (0.42 to 0.43) 65 0.01 (0.01 to 0.01) 494 0.43 (0.42 to 0.44) Source: Pennsylvania Patient Safety Authority. 2012 annual report [online]. 2013 Apr 30 [cited 2013 Nov 6]. http://patientsafetyauthority.org/ PatientSafetyAuthority/Documents/Annual%20Report%202012%20.pdf * Individual nursing homes may have reported both influenzalike illnesses and lower respiratory tract infections. † Rate calculation: number of infections ÷ number of resident-days x 1,000 ‡ Infection data collection for nursing homes began in July 2009. As a result, rates given are based on six months of data collection, and the numbers of nursing homes are not given because they are not equally comparable with subsequent years. Table 2. Influenza Vaccination Coverage among US Healthcare Workers, by Work Setting, 2010-2011 to 2012-2013 Flu Seasons WORK SETTING* 2010-2011, %† (N‡) 2011-2012, %† (N‡) 2012-2013, %† (N‡) Overall 64 (1,931) 67 (2,348) 72 (1,944) Hospital 71 (617) 77 (1,187) 83 (961) Long-term care facility 64 (220) 52 (455) 59 (427) Ambulatory care/physician office 62 (658) 68 (747) 73 (636) Other clinical setting 52 (436) 62 (277) 73 (237) Adapted from: Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel--United States, 2012-13 influenza season. MMWR Morb Mortal Wkly Rep 2013 Sep 27;62(38):781-6. * Respondents were able to select more than one work setting. † Weighted percent vaccinated ‡ Number of workers surveyed, by occupational setting and influenza season Page 138 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority healthcare facilities that are “considering Two of the priority goals noted in HHS’s HHS plans to create web-based educa- or contemplating” making immunization National Action Plan to Prevent Health tion and resources specifically targeting mandatory within their facility to help Care-Associated Infections: Road Map to long-term care employers. These resources them firm up their policy or develop Elimination are to (1) progress toward the are being developed in response to the program strategies.10 HAP has created a Healthy People goal of having 90% of needs, barriers, and opportunities identi- best-practices guide and toolkit that can healthcare workers receive influenza vac- fied by stakeholders at a September 2011 be adapted to the long-term care setting. cination by 2020, with 75% of healthcare workshop that addressed long-term care The toolkit is available at http://www. workers in long-term care receiving influ- providers. The resources include a toolkit, haponline.org/downloads/Universal_ enza vaccination by 2015, and (2) achieve planned for release by HHS during the Flu_Immunization_Programs_for_ 85% vaccination coverage of eligible 2013-14 influenza season, for increasing Health_Care_Personnel-HAP_Quality_ nursing home and skilled nursing facility influenza vaccination of healthcare work- Best_Practice_Series_Sept2011.pdf. residents for both influenza and pneu- ers in long-term care settings.13 mococcus within five years of the report’s publication in 2013.12 NOTES 1. Centers for Disease Control and Preven- quality measures and metrics compared 9. Centers for Disease Control and Preven- tion. Ten leading causes of death and to all states. 2008 state snapshots [online]. tion. Influenza vaccination coverage injury: causes of death by age group [cited 2013 Oct 1]. http://statesnapshots. among health-care personnel--United [online]. [cited 2013 Oct 1]. http://www. ahrq.gov/snaps08/meter_metrics.jsp?men States, 2012-13 season. MMWR Morb cdc.gov/injury/wisqars/leadingcauses. uId=14&state=PA&level=6&region=0&c Mortal Wkly Rep 2013 Sep 27;62(38):781-6. html ompGroup=N 10. The Pennsylvania Health Care Worker 2. Pennsylvania Patient Safety Authority. 6. Agency for Healthcare Research and Vaccination Taskforce. About this Healthcare-associated infections. Adden- Quality. Pennsylvania nursing home care resource [online]. [cited 2013 Oct 1]. dum H. In: 2012 annual report [online]. quality measures and metrics compared http://pahcwfluvax.org/about 2013 Apr 30 [cited 2013 Oct 1]. http:// to all states. 2009 state snapshots [online]. 11. Healthy People 2020. U.S. Department of patientsafetyauthority.org/PatientSafety [cited 2013 Oct 1]. http://statesnapshots. Health and Human Services. Immuniza- Authority/Documents/Annual%20 ahrq.gov/snaps09/meter_metrics.jsp? tion and infectious diseases: objectives: Report%202012%20.pdf menuId=14&state=PA&level=6&region= IID-12.9 [online]. [cited 2013 Oct 1]. 3. Bradley S. Strategies to improve out- 0&compGroup=N http://www.healthypeople.gov/2020/ comes in nursing home residents with 7. Agency for Healthcare Research and topicsobjectives2020/objectiveslist. modifiable risk factors for respiratory tract Quality. Pennsylvania: nursing home qual- aspx?topicId=23 infections. Pa Patient Saf Advis [online] ity measures and metrics compared to all 12. US Department of Health and Human 2011 Dec [cited 2013 Oct 1]. http:// states. 2011 state snapshots [online]. [cited Services (HHS). Long-term care facilities. patientsafetyauthority.org/ADVISORIES/ 2013 Oct 1]. http://statesnapshots.ahrq. Chapter 8. In: US HHS. National action AdvisoryLibrary/2011/dec8(4)/ gov/snaps11/meter_metrics.jsp?menuId= plan to prevent health care-associated Pages/131.aspx 14&state=PA&level=6&region=0&comp infections: road map to elimination April 4. Increasing influenza and pneumonia vac- Group=N 2013 [online]. [cited 2013 Oct 30]. http:// cination rates in long-term care. Pa Patient 8. Centers for Disease Control and Pre- www.hhs.gov/ash/initiatives/hai/ Saf Advis [online] 2009 Dec [cited 2013 vention. Health care personnel flu actionplan/hai-action-plan-ltcf.pdf Oct 1]. http://patientsafetyauthority.org/ vaccination Internet panel survey, United 13. Stone N. HAI action plan metrics—LTCF ADVISORIES/AdvisoryLibrary/2009/ States, November 2012 [online]. 2013 Jul update. Presented at: Road Map to Elimi- Dec6(4)/Pages/132.aspx 17 [cited 2013 Oct 1]. http://www.cdc. nate HAI: 2013 Action Plan Conference; 5. Agency for Healthcare Research and gov/flu/fluvaxview/hcp-ips-nov2012.htm 2013 Sep 25-26; Washington (DC). Quality. Pennsylvania nursing home care Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 139 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 4—December 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. 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