Improving Tdap Immunization: A Growing Role for Hospitals and Health Systems

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Immunizing Health care Workers: “Everybody’s Responsibility” Outbreaks of pertussis have occurred in hospitals, EDs, and outpatient clinics, with infection spread by health care workers, patients, and visitors.5 The CDC recommends that facilities provide Tdap to their health care personnel and take steps to maximize vaccination rates, using strategies that have worked well for other hospital-based immunization campaigns, such as for influenza. About 7 years ago, Ruth Carrico, PhD, RN, FSHEA, CIC, Associate Professor in the Department of Health Promotion and Behavioral Sciences at the University of Louisville, started a program to help employers implement CDC recommendations for health care worker immunization. Since then, she has conducted numerous educational “bootcamps” for staff in hospitals, health systems, offices, and long-term care settings throughout Kentucky. Although national vaccine guidelines are a critical source of information in implementing health care personnel immunization programs, they lack the “how-to” information needed by infection preventionists and employee and occupational health professionals working on a local level, especially in the private sector, said Dr. Carrico. “So we’ve got this big practice gap. Closing that gap is everybody’s responsibility,” she said, “and an opportunity for professional [health care] organizations to become more actively involved in providing guidance.” While Dr. Carrico’s efforts are aimed primarily at infection preventionists, who are either directly responsible for employee health programs or help develop the policies, “we also have to educate physicians who provide oversight for the occupational health department,” she said. “This person is usually an infectious disease physician, but in a smaller hospital, it may be a physician from another specialty, such as pathology or internal medicine. In some settings, it may be a physician without expertise in immunization. They all need information so immunization programs can be developed and implemented safely.” Dr. Carrico recently finished developing a health care worker immunization toolkit funded by the US Department of Homeland Security and administered

by the National Institute for Hometown Security. The toolkit is due to be disseminated nationwide beginning in June 2012 and can be downloaded from Dr. Carrico’s website, www.infectionpreventiontools.com. The kit is a mixture of documents available from the CDC and tools and resources developed by Dr. Carrico. The toolkit contains sample standing orders, information on vaccine administration and adverse reactions, a performance-skills checklist, and sample immunization records used for electronic tracking, among other items. These documents, said Dr. Carrico, “make it easy for people to do the right thing and hard for them to do the wrong thing.” Part of an effective health care worker immunization program is making it hard for employees to say “no,” said Dr. Carrico. Some facilities have implemented mandatory immunization for their workers.10 Two key issues that each facility must decide upon are what constitutes a valid exception to immunization and what actions should be taken if

an employee is unable to be immunized (see the box below for the approach taken at one health system). The CDC recommends vaccinations “because data show that it benefits our communities and protects our health care workers and patients,” said Dr. Carrico. Although based on evidence, the recommendations do not have the force of law. “But should it matter to us whether this is law or not? The CDC recommendations are best practice, and we are compelled to implement best practice.” Key Ingredients for Success What are some of the common elements that make a Tdap immunization strategy work? Find strong vaccine champions. A single individual or a group of people can make change happen and keep it going. “You have to have somebody who’s going to champion the cause, and then go back and talk to the staff to find out how they’re doing and whether they need additional resources to

Minding Your Respiratory Etiquette In 2003, a countywide outbreak of pertussis occurred in Fond du Lac, Wisconsin, one of the communities served by the Agnesian HealthCare network.11 The outbreak lasted 9 months and led to the creation of respiratory etiquette policies at Agnesian HealthCare that remain in place today. “Anyone coming into our facilities with cough, fever, or any kind of respiratory symptoms must wear a mask,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Agnesian HealthCare, who was instrumental in developing the policies. Respiratory stations are located in designated areas throughout the outpatient clinic and in the hospital, making it easy for patients to access masks and hand sanitizer. Working in collaboration with the public health department, “we came up with educational pieces that are handed to patients with suspected pertussis,” outlining steps they should take to lower the likelihood they will spread the disease, said Ms. Ericksen. The staff receives annual, online, mandatory training on communicable disease and respiratory etiquette, as well as on immunizations and their importance. In 2011, Agnesian HealthCare initiated mandatory influenza vaccinations for its 3000 employees, and is in the process of enhancing its Tdap immunization program, which currently offers free vaccine to new and current employees. The flu immunization program serves as a compelling model: the employee coverage rate is virtually 100%, up from 57% in the 2010-2011 flu season. Exemptions are allowed for medical contraindications and religious reasons; exempted employees must wear masks while influenza is active in the community. These and other measures for infection control and prevention—including standing orders for Tdap vaccination of expectant moms—were spurred by a multidisciplinary team of personnel from pharmacy, infection prevention, obstetrics, employee and occupational health, and outpatient clinic, as well as members of the Fond du Lac County Public Health Department, which Ms. Ericksen describes as “key in our collaboration.” Community outreach in concert with the health department, such as sending out joint statements on health matters, remains a critical element in the network’s approach to disease prevention.

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awareness of pertussis and of the health system’s free Tdap immunization program. Said Dr. Janczak, “The more times you can get the information out, the better.”

keep the program sustainable,” said Dr. Tan. Encourage a spirit of collaboration. “It helps when you can collaborate within the health care system and with the public health department,” said Kayla Ericksen, RN, BSN, Infection Preventionist at Ag nesian HealthCare. “You need to do an assessment of your community and your health care facility and take a look at where you can make inroads. Sometimes you’ll find a group of people who are like-minded and have a passion for immunization.” Educate, educate, educate. Extensive training and education on the importance of Tdap vaccine and the institution’s protocols for its use is perhaps the most important facet of program implementation—and likely the most time-consuming. But education can take many forms, from in-services and online modules to e-mails and handouts. Ongoing education is vital to success. Use technology effectively. Electronic health records and computerized clinical decision support tools can alert clinicians to screen patients for immunization, track vaccine acceptance and usage, and automatically direct clinicians to the most appropriate vaccine via algorithms and default settings.12 Keep it simple. Adopt straightforward protocols—such as standing orders and “optout” immunization requirements—aided by uncomplicated tools. Cheat sheets for clinicians, posters, and customizable printed pamphlets for families are low-tech but effective. Measure and assess. “You can’t assume you’re doing well. Hard data identifies gaps and helps you improve,” said Dr. Carrico, who recommends having specific goals such as which patient subset is to be targeted, and then track how many are immunized. If the data are poor, questions to ask include “Who are we missing?” and “Why are we missing them?” In regard to health care workers, “What reasons do they give for declining immunizations? What additional information is needed to influence their decision?”

Challenges to Meet How successful a health facility’s Tdap immunization strategies prove to be will depend on how well several basic challenges are addressed. Staff buy-in. The compliance and support of staff is predicated on understanding the new strategies and protocols—and on being convinced that those changes are for the best. Reinforcing both aspects will likely require continued education and outreach, to the health care staff as well as the community. “Getting the word out within a large system remains a challenge,” as does getting enough feedback from staff, said Dr. Janczak. To make new programs like this work, “communication needs to be a 2-way street.” Immunization of key contacts. Cocooning programs have been more successful in immunizing mothers than they have been in vaccinating fathers and other family members.8 Difficulties in vaccinating close contacts can include state-specific legal complexities pertaining to non-patients, as well as practical and logistical concerns,6 such as when and where to vaccinate close contacts, the lack of a medical record, and how to document vaccine administration. Also, how to assure that contacts referred to a clinic or primary provider are immunized? Some hospitals do immunize key contacts on the spot. Stony Brook University Medical Center in New York, for example, immunizes moms and other family members of neonatal intensive care unit infants at the bedside.13 Cost. Program expenses include the cost of purchasing and administering the vaccine and of any added resources devoted to a program, such as staffing. Many postpartum Tdap programs have been able to provide free immunizations to patients and family members by obtaining donated vaccine— from a state immunization program, public health department, or vaccine manufacturer—or by purchasing it with funding from a philanthropic organization. Despite the challenges, the initiatives

described here show that hospitals and health systems are finding ways to implement new immunization strategies, demonstrating a desire to follow best practices and expand their focus beyond traditional bounds. “Health care overall does a very good job in the treatment of disease,” notes Dr. Janczak. “We need to do a better job at prevention.”

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Improving Tdap Immunization

A Growing Role for Hospitals and Health Systems

References 1. Centers for Disease Control and Prevention (CDC). Adult vaccination coverage — United States, 2010. MMWR. 2012; 61(4):66-72. 2. CDC. National and state vaccination coverage among adolescents aged 13 through 17 years—United States, 2010. MMWR. 2011;60(33):1117-1123. 3. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR. 2011;60(1):13-15. 4. Advisory Committee on Immunization Practices (ACIP). ACIP provisional Tdap recommendations. March 21, 2012. http:// www.cdc.gov/vaccines/recs/provisional/Tdap-feb2012.htm. Accessed April 30, 2012. 5. CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health care personnel. MMWR. 2006;55(RR-17):1-37. 6. Healy CM, Rench MA, Baker CJ. Implementation of cocooning against pertussis in a high-risk population. Clin Infect Dis. 2011;52(2):157-162. 7. Castagnini LA, Healy CM, Rench MA, Wootton SH, Munoz FM, Baker CJ. Impact of maternal postpartum tetanus and diphtheria toxoids and acellular pertussis immunization on infant pertussis infection. Clin Infect Dis. 2012;54(1):78-84. 8. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) in pregnant women and persons who have or anticipate having close contact with an infant aged <12 months — Advisory Committee on Immunization Practices (ACIP), 2011. MMWR. 2011;60(41):1424-1426. 9. Tan TQ, Gerbie MV: Pertussis and patient safety: implementing Tdap vaccine recommendations in hospitals. The Joint Commission Journal on Quality and Patient Safety. 2010;36(4):173-178. 10. The Joint Commission. Health Care Personnel and Pertussis. In: Tdap Vaccination: Strategies from Research and Practice. Oakbrook Terrace, IL: The Joint Commission; 2011:31-64. 11. Sotir MJ, Cappozzo DL, Warshauer DM, et al. A countywide outbreak of pertussis: initial transmission in a high school weight room with subsequent substantial impact on adolescents and adults. Arch Pediatr Adolesc Med. 2008;162(1): 79-85. 12. Trick WE, Linn ES, Jones Z, et al. Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination. Obstet Gynecol. 2010;116(1):51-57. 13. Dylag AM, Shah SI. Administration of tetanus, diphtheria, and acellular pertussis vaccine to parents and high-risk infants in the neonatal intensive care unit. Pediatrics. 2008;122(3):e550-e555.

© Jochen Sands/Getty Images

Five immunization advocates took the time recently to share their experiences, insights, and success stories in Tdap vaccination and pertussis prevention efforts. Tina Q. Tan, MD Feinberg School of Medicine Northwestern University Children’s Memorial Hospital Chicago, Illinois

Randolph Cordle, MD, FACEP Carolinas Medical Center Charlotte, North Carolina

Don Janczak, MS, PharmD, BCPS, CPHQ Mercy Health System Janesville, Wisconsin

Ruth Carrico, PhD, RN, FSHEA, CIC School of Public Health and Information Sciences University of Louisville Louisville, Kentucky

Kayla Ericksen, RN, BSN Agnesian HealthCare Fond du Lac, Wisconsin

Faculty Reviewer

Flor M. Munoz, MD Assistant Professor Department of Pediatrics Infectious Diseases Section Baylor College of Medicine Houston, Texas

Brought to you as an educational service by Sanofi Pasteur Inc. 5

Improving Tdapa Immunization

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mmunization has traditionally been viewed as the domain of primary care providers working in medical offices. But that paradigm has changed over the last decade, especially for adults, many of whom do not make regular health care visits. Even when adults do seek primary care, missed immunization opportunities by providers remain a stubborn obstacle to improving immunization rates. Vaccination rates for adults in the United States are poor, particularly when it comes to preventing pertussis. Although booster immunization against pertussis has been recommended for adults since 2005, the estimated coverage for tetanus, diphtheria, and acellular pertussis (Tdap) vaccine among adults 19-64 years of age was just 8.2% in 2010.1 Among adolescents 13-17 years of age, coverage in 2010 was 69% (the Healthy People 2020 goal for Tdap immunization among 13- to 15-yearolds is 80%).2 In the absence of contraindications, everyone 11 years of age and older should receive a single dose of Tdap vaccine to help protect not only themselves but, by extension, those around them, especially infants, who are at greatest risk for severe complications of pertussis.3,4 Continued outbreaks of pertussis in the community, documented outbreaks of pertussis in health care facilities, and recently updated Tdap immunization guidelines from the Centers for Disease Control and Prevention (CDC) 3 make it clear that hospitals and health systems have a stake in immunizing patients, family members, and health care personnel. Every encounter—be it in the postpartum unit, emergency department (ED), or other inpatient or outpatient setting—represents a potential opportunity to immunize and help prevent the spread of pertussis. a  Tdap =   Tetanus, diphtheria, and acellular pertussis.

Postpartum Immunization: Completing the Cocoon In 2005, the Advisory Committee on Immunization Practices (ACIP) of the CDC recommended that close contacts of infants less than 12 months of age be immunized with Tdap vaccine to prevent transmission of pertussis to the baby (“cocooning”), and that postpartum women who had not been vaccinated prior to conception be immunized before hospital discharge.5 One of the first hospitals to put these recommendations into practice was Ben Taub General Hospital in Houston, which embarked on an ambitious postpartum Tdap immunization program, achieving rates of more than 90% among eligible women.6 It also established a “key contact” program, vaccinating at least 1 household contact of the newborn in approximately 60% of families who were interviewed by a program nurse.6 An outcomes study of the postpartum program at Ben Taub found that maternal postpartum Tdap vaccination alone was not sufficient to reduce the rate of pertussis among babies of immunized mothers.7 The authors conclude that efforts need to be directed not just at mothers but at all household and other key contacts of newborns.7 They also acknowledge that cocooning programs can be difficult and expensive to implement and note that new recommendations from the ACIP favor giving Tdap vaccine to women during the third or late second trimester rather than postpartum.8 Nonetheless, if mothers and key contacts are not immunized before the baby is born, then “targeting mothers during the postpartum period presents an invaluable opportunity for health care professionals to reach the entire household before the infant is discharged from the hospital, thus creating a protective barrier around


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