Improving influenza vaccine uptake in frontline staff Ann-Marie Aziz
Influenza is a highly contagious upper respiratory tract disease causing significant morbidity and mortality among high-risk groups. Immunization of frontline healthcare workers (HCWs) in the NHS is thought to be beneficial in reducing subclinical infection, staff sickness absences and protects patients. Each year Public Health England launches the Seasonal Flu Campaign to help reduce influenza transmission by reinforcing the message that it is vital that frontline HCWs get vaccinated. Public Health produces figures on frontline workers who have been vaccinated annually. The 2011/2012 campaign showed uptake figures of the influenza vaccine was averaging 44.6% nationally. The efforts of an NHS trust to increase staff uptake of the annual seasonal flu vaccination programme has been highly commended as it achieved an impressive 68.7% uptake against a target of 70%. This article shows how the trust worked hard to improve uptake on flu vaccinations for HCWs during the 2012/2013 flu season. Recognised as a Top Improver by NHS Employers (2013) for vaccination uptake, the Trust identifies how measures can be adopted to improve vaccination rates and what barriers can prevent total compliance. High rates of HCW vaccination can benefit staff, patients and the communities within which they work and live. Key words: Top Improver ■ Influenza ■ Vaccination ■ Flu Campaign ■ Healthcare workers
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nfluenza is caused by a virus, which was first identified in 1933. Influenza is a highly contagious upper respiratory tract disease causing significant morbidity and mortality in the elderly and among other highrisk groups. Symptoms include headache, fever, cough, sore throat, aching muscles and joints. There is a wide spectrum of illness ranging from minor symptoms through to pneumonia and death (Apisarnthanarak et al, 2004). The flu virus is highly contagious and easily passed from person to person when an infected person coughs or sneezes. Transmission can also occur by touching a surface contaminated with respiratory secretions and then putting the fingers in the mouth or nose or near the eyes (Bridges et al, 2003). The flu virus
Ann-Marie Aziz is Clinical Lead: Infection Prevention and Control, Pennine Care NHS Foundation Trust Accepted for publication: November 2013
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can live on a hard surface for up to 24 hours and a soft surface for around 20 minutes. The incubation period (the period between infection and the appearance of symptoms) is about 2–3 days. Although the virus has been detected before symptoms appear, adults are usually considered infectious once appear and for 3-5 days afterwards (Flahault, 2006). This period is longer in children.
Recommendations for the use of the vaccines Public Health England has updated ‘The Green Book’ in November 2013. The Green Book has the latest information on vaccines and vaccination procedures for all the vaccinepreventable infectious diseases that may occur in the UK. Chapter 19 is dedicated to influenza and includes material on the influenza immunisation programme (Public Health England, 2013a). The objective of the programme is to protect those who are most at risk of serious illness or death should they develop influenza and to reduce transmission of the infection, thereby contributing to the protection of vulnerable patients who may
have a suboptimal response to their own immunisations (Public Health England, 2013a). To facilitate this, general practitioners are required to proactively identify all those for whom influenza immunisations are indicated and to compile a register of those patients for whom influenza immunisation is recommended. Sufficient vaccine can then be ordered in advance and patients can be invited to planned immunisation sessions or appointments. Given that some influenza vaccines are restricted for use in particular age groups, the summaries of product characteristics (SPCs) for individual products should always be referred to when ordering vaccines to ensure that they can be given appropriately to particular patient age groups. Patients should be advised that many other organisms cause respiratory infections similar to influenza during the influenza season, e.g. the common cold and respiratory syncytial virus. Influenza vaccine will not protect against these diseases. Influenza vaccine should be offered, ideally before influenza viruses start to circulate to: ■■ All those aged 65 years or older, to include all those aged 65 years on or before 31 March 2014 (born on or before 31 March 1949) ■■ All children aged 2 years or 3 years, but not 4 years or older on or before the 1 September 2013 (date of birth on or after 2 September 2009 and on or before 1 September 2011) ■■ All those aged 6 months or older in the clinical risk groups shown in Table 1 (The Green Book, Chapter 19, Public Health England, 2013a).
Influenza vaccination for health care workers Frontline healthcare workers (HCWs) involved in direct patient care are encouraged to receive annually the seasonal influenza vaccination to protect themselves and their patients from influenza (Department of Health (DH), 2012a) It is difficult to avoid infection if there is an epidemic. Keeping away from crowded places
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Abstract
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Clinical risk groups
Examples (decision based on clinical judgement)
Chronic respiratory disease
Chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD) Asthma - with disease which requires continuous or repeated use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission Children who have previously been admitted to hospital for lower respiratory tract disease
Chronic heart disease
Congenital heart disease Hypertension with cardiac complications Chronic heart failure Chronic heart failure Individuals requiring regular medication and/or follow-up for ischaemic heart disease
Chronic kidney disease
Chronic renal failure Nephrotic syndrome Renal transplantation
Chronic liver disease
Cirrhosis Biliary atresia Chronic hepatitis
Chronic neurological disease
Stroke Transient ischaemic attack (TIA)
Diabetes
Type 1 diabetes Type 2 diabetes requiring insulin or oral hypoglycaemic drugs Diet-controlled diabetes
Immunosuppression
Immunosupression due to disease or treatment Patients undergoing chemotherapy leading to immunosuppression Asplenia or splenic dysfunction HIV infection Individuals treated with, or likely to be treated with, systemic steroids for more than a month at a dose equivalent to prednisolone at 20 mg or more per day (any age) or, for children under 20 kg, a dose of 1 mg or more per kg per day Some immunocompromised patients may have a suboptimal immunological response to the vaccine
Asplenia or dysfunction of the spleen
This also includes conditions such as homozygous sickle cell disease and coeliac syndrome that may lead to splenic dysfunction
Pregnancy
All pregnant women should receive the trivalent seasonal influenza vaccine
Source: The Green Book, Chapter 19, Public Health England, 2013a
can reduce the risk of becoming infected and spreading it to others. A previous flu infection or vaccination will not necessarily provide protection against further infections because the virus is continually changing genetically and different subtypes circulate each winter. The viruses that cause flu frequently change, so any immunity produced by the flu shot will possibly decrease in the year after vaccination, people in high-risk groups should be vaccinated every year (Woodman, 2001). The best time to be vaccinated is between late September and early November, ready for the winter (World Health Organization, 2005).
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healthy people can develop more serious consequences and can require hospitalisation ■■ Patients: staff incubating or even suffering from flu can unintentionally pass this on to patients they are looking after. If the patients are ill, elderly or suffering from a variety of chronic conditions this can lead to serious illness and even death (Qureshi et al, 2004) ■■ Service continuity: if large numbers of staff require a week off work with flu, the service’s ability to keep looking after ill patients is severely curtailed with the likelihood of ward closures and cancelled clinics.
The Influenza Campaign The 2012/2013 Seasonal Flu Campaign (DH, 2012) was a campaign launched to help reduce the spread of cold, flu and other viruses. The campaign sets about reducing influenza transmission by reinforcing the message that it is vital that frontline HCWs get vaccinated. It promotes the message that people should cover their nose and mouth when they cough and sneeze, preferably with a tissue, and wash their hands afterwards. The campaign includes widespread ambient advertising promoting CATCH IT, BIN IT, KILL IT, appearing in health settings, on buses, trains and tubes and in offices and major shopping centres, reminding people how to avoid spreading germs when they sneeze and cough. Public Health England produces figures on frontline workers who have been vaccinated annually. The 2012/2013 campaign showed uptake figures of the influenza vaccine was averaging 45.6%, this compared with 44.6% in 2011/12 (Figure 1). Figure 2 shows the highest seasonal influenza vaccine uptake was among GP practice nurses (60.6%) and the lowest seasonal influenza vaccine uptake was among qualified nurses (excluding GP practice nurses) (40.1%). Figure 3 shows uptake for each survey month.
Rationale for vaccination
Vaccination uptake
Immunization of HCWs is thought to be beneficial in reducing in subclinical infection and reducing the level of sickness absences and effective in reducing nosocomial infections among elderly patients at risk (Carman et al, 2000; Hayward et al, 2006). It is important that the benefits of flu vaccination are communicated to all staff. The potential consequences of getting influenza due to not being immunised are: ■■ Personal: influenza is not a minor illness even in normally fit people. It makes people feel extremely unwell for 2–3 days and full recovery normally takes a week. Even fit and
The 2012/2013-influenza season has seen an increase in uptake of seasonal influenza vaccine among HCWs in the NHS. NHS frontline workers have achieved an impressive 45.6% uptake of the flu vaccination during last year’s campaign. This was against the national target of 70% for vaccinating frontline workers (DH, 2012).
How was the influenza vaccination uptake achieved? Low uptake of seasonal flu vaccination by HCWs continues to be an issue in the NHS (Public Health England, 2013b). While
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Table 1. Clinical risk groups who should receive the influenza immunisation
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clinical focus
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1. Planning delivery Vaccination clinics should, as far as possible, be arranged at the place of work and should include clinics during early, late and night shifts, at convenient areas throughout the Trust. Clinics were run efficiently with administrative support to deal with paperwork, to manage staff and data collection. This resulted in staff having quick, easy access to the vaccine. Dropin clinics were also made available for staff unable to make their designated appointment
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Seasonal influenza vaccine uptake in Healthare Workers (HCWs) in England by strategic health authority in 2012/13 compared to 2011/12 60 55
58.9 54.9
n 2011/12 vaccine uptake (%) n 2012/13 vaccine uptake (%)
56.1 53.3
52.8
50
47.6
45
49.1 46.1 41.9
40
41.7
40.2
44.5
43.7
42.7
36.0
35
37.8
39.0
39.6 37.6
38.7
30 25 20 15 10 5 0
North East
North West Yorkshire & The Humber
East Midlands
West Midlands
East of England
London
South East Coast
South Central
South West
Strategic Health Authority (SHA)
Figure 1. Seasonal influenza vaccine uptake amongst frontline HCWs by SHA in England Winter season 2012/13 (Public Health England, 2013b).
Seasonal influenza vaccine uptake in Healthcare Workers (HCWs) in England for 2012/13 compared to 2011/12 70
n 2011/12 vaccine uptake (%) n 2012/13 vaccine uptake (%)
65
60.6
60
58.1
55 Vaccine uptake %
vaccination of NHS staff remains voluntary, it is encouraged that staff are offered the vaccine in an accessible way, and all staff to seriously consider the benefits to themselves and their patients. Plans to improve vaccination rates by NHS Trusts are instigated annually and are part of a plan to help staff keep well during the winter. Many NHS Trusts commence influenza campaigns early to identify and bring together key members to attend influenza vaccination meetings and enlist flu champions who are members of staff who play a pivotal role in cascading the initiatives of the campaign. The Flu Campaign leader can be a member of staff within the Trust who has authority to arrange meetings and define leadership qualities to influence and create the importance of the campaign. Other key members that can be included in the campaign can be: ■■ Pharmacy staff ■■ Occupational health department ■■ Community district nurses ■■ Communications staff ■■ Infection prevention and control staff ■■ Staff Side (staff union representative) ■■ Flu Champions. Monthly meetings can be held by the group, with a schedule of agenda and previous minutes being sent to members in advance. Discussions at the meetings can incorporate lessons learnt from previous years, the plans for the flu season and how to promote awareness among HCWs (NHS Employers, 2012). Pharmacy staff discussed matters such as obtaining vaccines, quantity of vaccines and storage. It is important to involve staff side in the campaign. Not only do they provide valuable input to the planning of the campaign, they also help the influenza campaigners reach and communicate with many staff effectively. Their skills and networks help to provide effective partnership working and spread the message of the campaign. These, and many other reasons, can contribute to the success of campaigns and increase flu vaccination uptake. Other strategies that can contribute are:
50 45
51.2
52.7 48.8
44.6 45.6
44.4
46.0 42.5
45.2
44.7
48.0
49.1
40.2 41.1
39.3 40.1
40
50.8
46.3
35 30 25 20 15 10 5 0
All HCWs
All doctors (excl. GPs)
GPs only
All doctors Nurses (excl. GP practice (incl. GPs) GP practice nurses only nurses)
Staff group
Support to All nurses Allied clinical staff (incl. GP health practice professionals nurses)
Support to GPs
Figure 2. Seasonal influenza vaccine uptake amongst frontline HCWs in England Winter season 2012/13 (Public Health England, 2013b).
or who may have changed their mind. Options for delivery included: ■■ Setting up clinics in staff rooms or areas close to wards ■■ Setting up in the staff canteen ■■ Offering vaccinations out of hours ■■ Sending vaccinators to wards and departments to catch staff who are traditionally difficult to access ■■ Running clinics at places you are likely to find community-based staff ■■ Allowing staff to ‘drop in’ to a clinic at any
time that suits them peer vaccinators to vaccinate colleagues ■■ Training ward managers to vaccinate their own staff (or to swap with another manager and vaccinate their staff). ■■ Using
2. Setting targets and monitoring uptake Setting targets initially in the influenza campaign is important, as it gives vaccinators something to aim for and an incentive.
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Vaccine uptake %
40
30
All doctors (including GPs)
20
All qualified nurses (including GP practice nurses) All other professionally qualified clinical staff Total (all HCWs)
10
October
November
December
January
Survey month Figure 3. Healthcare workers vaccine uptake for each survey month (Public Health England, 2013b).
Vaccinating staff can be encouraged to aim to vaccinate 100% of front line staff. With the emphasis that particular priority should be given to staff working in areas where patients might be at particularly high risk (paediatric and care of elderly) (Anikeeva et al, 2009). Numbers of those staff vaccinated can be distributed monthly at influenza campaign meetings. Attendees at the meetings can review the numbers of staff vaccinate and address areas were numbers are low and what is working well at separate departments to aid in delivering good practice trust-wide.
b Get the ja safe
Get flu
Are you at risk from flu? Flu can be really serious. Getting a flu jab can protect you all winter. It’s free if you are pregnant, over 65 or have a health condition such as severe asthma, diabetes, a chest, heart, liver or kidney complaint, or lowered immunity.
It’s quick, safe and free. To book your jab, speak to your GP practice today.
jab The flu ve can’t gi you flu
www.nhs.uk/flu
Figure 4. Get the Flu Jab (NHS Employers, 2012)
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3. Vaccine supply The Seasonal Flu Plan is published annually and sets out arrangements for the ordering of vaccine for the annual seasonal flu programme. Pharmacy department completed the processing of orders in March, prior to the campaign starting. After calculations of staff on the frontline, a sufficient numbers of vaccines were ordered and deposited in various sites across NHS Trusts, awaiting distribution. Once orders were placed, suppliers were able to confirm their delivery schedule. Vaccine supply should not relinquish during the flu season, and if supplies are reducing in NHS Trusts, then correspondence can be made via the influenza campaign champions to ascertain were stocks could be accessed (DH, 2011).
4. Staff vaccination champions The flu champions should be nominated early on in the programme, and can provide support at meetings to other members of staff. Flu champions can be service managers and senior members of staff. It is necessary to ensure that all flu champions had the skills and knowledge to raise awareness and answer any questions staff may have in relation to the vaccine. The influenza meetings can highlight issues, such as staff choosing not to be vaccinated and if vaccination clinics are accessible. This can reinforce the importance of ensuring staff have access to up-to-date information about the risks and benefits of seasonal flu vaccine, and promoting vaccination as a positive choice. It has been shown that a 'Flu Champion' can have a positive influence on vaccination uptake (Health Protection Agency (HPA), 2012a).
5. Effective leadership Organisations where senior leaders support and promote the vaccination tend to have higher uptake rates than those that do not (Heimberger et al, 1995). NHS Trusts can improve the profile of the influenza campaign by taking photographs of their directors and other senior staff, such as consultants, being vaccinated. It is necessary that support from senior staff be gained early in the campaign as this can help to engage staff and give the effective leadership the campaign needs. Effective leadership helps to: ■■ Encourage immediate line managers to lead in encouraging their staff to take the vaccines and arranging for them to get vaccinated ■■ Encourage managers to promote positive messages and encourage staff to attend clinics ■■ Have senior clinicians acting as champions ■■ Have ‘respected’ staff publicly immunised ■■ Make sure the campaign was added to local Governance agendas.
6. Communications Communication is vital to promote uptake of the vaccine by staff to support local efforts and raise awareness of the vaccine. NHS trusts can send letters and flyers to staff inviting them to attend a specific clinic at/near to their place of work. The purpose of the invitations was not only to organise clinics, but also to encourage individuals to consider having the vaccine and to make a decision. To promote good levels of uptake, invitations can be sent out 2 weeks before commencement of the campaign to raise awareness within the organisation. Posters can be placed in prominent areas in NHS Trusts to promote flu vaccination (Figure 5). Emails can be sent to all staff on a weekly basis via NHS Trusts intranet giving information on the campaign and achievements towards the target of 70%.
7. Publicity and information materials It is important that influenza promotional campaigns deliver a marketing and awarenessraising crusade to promote uptake of the vaccine. This is to ensure that colleagues have enough time to display information and to prepare for the programme. The materials can be created in collaboration with NHS staff to get a consensus on their suitability. The materials created can be: ■■ An information leaflet containing key messages ■■ A poster with details of vaccination clinics
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Seasonal influenza vaccine uptake in Healthcare Workers (HCWs) by staff group for England 2012/2013 50
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clinical focus ■■ Dedicated
site on the Trust intranet where influenza material could be obtained In addition to these materials, the marketing campaign also included radio and PR activities with local and national media (NHS Employers, 2013a). A FAQ document should be available ahead of the start of the season that could be accessed on the HPA website via the trust intranet (2013). This document addresses the most common questions from professionals about vaccines, risk groups and seasonal flu. The Influenza chapter of the Immunisation against Infectious Disease (the ‘Green Book’) can also be made available, should staff wish to refer to it at any time (Public Health England, 2013a).
8. Education and training All NHS Trusts make great strides in reducing the spread of flu by vaccinating as many frontline staff as possible. However, as a local initiative it is necessary to provide education and training on influenza as the flu season approaches. Infection prevention and control training was revised to include necessary elements of containing respiratory infections (HPA, 2012b). Components of the training focused on: ■■ Containment of respiratory secretions (Catch it, Bin it, Kill it practices) ■■ Nurse patients with proven or suspected influenza in a side room ■■ Strict adherence to infection control principles and droplet precautions ■■ Use of personal protective equipment (PPE) ■■ Restriction of symptomatic workers and visitors ■■ Promoting staff vaccination.
2. Opening times of some clinics were restrictive This may have prevented staff attending. Therefore, future plans are required to ensure clinics are more accessible.
3. Vaccinating clinics and administration Influenza clinics that are well-organised can have good attendance. Pre-scheduled lists of staff for clinics ensure there are enough vaccines available enabling many more staff to be vaccinated. When clinics become busy it helps if arrangements are made to: ■■ Have a dedicated member of staff to complete the paperwork, while 1 or 2 nurses vaccinate ■■ Photocopy consent forms with the batch number on to save time ■■ Vaccinate those staff on lists first before drop-in staff – to avoid running out of vaccines. It was also necessary to ensure prospective
6. Lack of time to access information sent electronically
1. Staff not being released to attend clinics due to work pressures and commitments © 2013 MA Healthcare Ltd
A PGD is a written direction, signed by a doctor and agreed by a pharmacist, so a nurse can administer prescription-only medicines (POMs) to patients or staff using their own assessment of patient need, without necessarily referring back to a doctor for an individual prescription (Royal College of Nursing, 2004). The Seasonal Influenza Administration for Staff PGD helps to deliver vaccinations to staff. To complete the PGD, staff had to attend training on ‘Immunisation and Vaccination’, anaphylaxis training and basic life support. Staff also had to complete a PGD for adrenaline. Once this training was undertaken, it was requested their managers signed off the PGD and staff were then deemed competent to administer the flu vaccination.This laborious process can impede many staff from administrating the vaccination in their workplace, as it takes so long to complete. Plans to address these matters should be included in the preparatory planning phase of the influenza campaign.
It can be difficult to find the capacity to train extra potential vaccinators to help deliver the programme. Staff require annual updates to vaccinate under the PGD. This is a financial implication for training departments in the NHS, as it means more training and more resources. More staff training to administer the vaccination should be included in the influenza campaign plans.
NHS Trusts work hard to improve uptake on flu vaccinations for HCWs during the influenza season. However, there are still elements in the campaign that are more challenging than others. The factors that may impact on organisations not achieving its target of 70% influenza uptake are:
British Journal of Nursing, 2013, Vol 22, No 21
4. Patient Group Directive (PGD)
5. Staff not trained to give vaccination
Lessons learnt and recommendations
It is vital that managers understand the benefits of vaccination, not only so that they lead by example, but also so that they allow staff the time they need to get vaccinated. Off-duty rota in September to December are required to factor in and accommodate staff attending a vaccination clinic.
clinics had hand-washing facilities, a telephone and access to adrenaline and drug formularies. The issues with busy clinics should be addressed early in the campaign and suitable clinic venues should be nominated.
Figure 5. Jab-o-meter (NHS Employers, 2013b)
NHS staff can be very busy and may not have time to access information that is sent via emails about the flu campaign and vaccination clinics. It is important not to include too much text in the emails sent to staff, as they do not have the time to read them. Keeping the emails brief and to the point is key. Plans should be incorporated to include noncomputer based literature and a visual display of the campaign achievements so staff can see progress at a glance. The Flu Fighter Jab-ometer (Figure 5) is an effective info graphic that should inform and appeal to staff (NHS Employers, 2013b).
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n Influenza is a highly contagious upper respiratory tract disease that causes significant morbidity and mortality n The Seasonal Flu Campaign is launched annually to help reduce the spread of cold, flu and other viruses. n Influenza vaccination of frontline healthcare workers (HCWs) is required annually n There was an average 45.6% of frontline HCWs vaccinated in the 2012/2013 influenza campaign n It is necessary to commence the Influenza Campaign early n To overcome barriers and increase uptake, vaccination campaigns must be carefully designed and implemented taking account of the specific needs at each organisation
7. Myths that prevented staff being vaccinated Clinical staff can often believe things that simply are not true, and our job is to change this. Many HCWs who do not get vaccinated say it is because the vaccination makes them feel unwell or think it causes them to get the flu. Staff may not get the vaccination in case it results in them staying off work. Ensuring that staff can access the truth is vital. The use of the intranet page is useful to include, staff newsletters and magazines, emails and notice boards, as well as team meetings and briefings, to pass these messages on. ‘Myth busters’ should be included in all influenza campaigns to dispel any worries that staff may have when considering the vaccination.
staff to get vaccinated messages to email footers: ‘I’ve had my flu jab, have you?’ ■■ Send text messages to colleagues with work mobile phones ■■ Use screensavers and pop-ups on all trust computers ■■ Create competition between departments and give awards to teams with the highest uptake ■■ Use personal stories/experiences of staff in our campaign ■■ Sell the vaccine as a personal benefit rather than just a way of stopping people from being off sick ■■ Set up an email address for staff to submit their questions.
Recommendations
Conclusion
Although many NHS trusts do not achieve the target of 70% vaccination uptake, it is important that measures are incorporated into influenza campaigns to reach as many staff as possible. Bringing the vaccination to the staff is a major factor for vaccination of frontline staff success. NHS Trust induction programmes for new starters are a key time to access staff. Having the opportunity to talk to new staff is beneficial as information can be given about the vaccine and its benefits, and promote it as the norm before staff hear the wrong information from other sources. This can help with new entrants to NHS organisations. Other recommendations, for future planning are: ■■ Attach messages to payslips to encourage
NHS Trusts views seasonal influenza vaccination as a serious patient safety issue, given the impact of influenza infection. Having well-organised and well-planned influenza campaigns can improve vaccination rates and identify the barriers that can prevent total compliance. To overcome these barriers and increase uptake, vaccination campaigns must be carefully designed and implemented taking account of the specific needs at each trust. High rates of HCW vaccination will benefit patients, HCWs, their families and the communities within which they work and live. Many NHS Trusts have strived to improve vaccination rates for their front-line staff and this has helped to reduce the spread of infection to patients and
■■ Add
carers. However, we should not be complacent in our efforts to continually improve. Plans should always be in place to advance from BJN improving to out-performing. Conflict of interest: none Anikeeva O, Braunak-Mayer A, Rogers W (2009) Requiring Influenza Vaccination for Health Care Workers.Am J Public Health 99(1): 24–9 Apisarnthanarak A, Kitphati R, Thongphubeth K et al (2004) Atypical Avian Influenza (H5N1). Emerg Infect Dis 10(7): 1321–24 Bridges CB, Kuehnert KJ, Hall CB (2003) Transmission of influenza: implications for control in hospital settings. Clinical Infectious Diseases 37(8): 1094-1101 Carman WF, Elder AG, Wallace LA et al (2000) Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 355(9198): 93–7 Department of Health (2011) Accessing the flu vaccine strategic reserve in England. http://tinyurl.com/lwpafl8 (Accessed 20 November 2013) Department of Health (2012) Seasonal flu plan. Winter 2012/13. http://tinyurl.com/cokb4rb (Accessed 11 November 2013) Flahault A, Vergu E, Coudeville L, Grais RF (2006) Strategies for containing a global influenza pandemic. Vaccine. 24(446): 6751-5 Hayward et al (2006) Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 333(7581): 1241-7 Health Protection Agency (2012a) Increasing influenza immunisation uptake in pregnant women. http://tinyurl.com/ kpgas8p (accessed 20 November 2013) Health Protection Agency (2012b) Infection control precautions to minimise transmission of respiratory tract infections (RTIs) in the healthcare setting. http://tinyurl.com/ktyuz8q (accessed 20 November 2013) Health Protection Agency (2013) Frequently asked questions on influenza. http://tinyurl.com/mpj5r2x (accessed 20 November 2013) Heimberger T, Chang H, Shaikh M et al (1995) Knowledge and attitudes of healthcare workers about influenza: why are they not getting vaccinated? Infect Control Hosp Epidemiol 16(7): 412-5 NHS Employers (2012) Running your flu fighter campaign. http://tinyurl.com/p8jra56 (accessed 20 November 2013) NHS Employers (2013a) Flu Fighter Campaign- Materials. http://tinyurl.com/lgfafe9 (accessed 20 November 2013) NHS Employers (2013b) Use the Jab-o-meter in your local campaign. http://tinyurl.com/kyvceqs (Accessed 20 November 2013) Public Health England (2013a) The Green Book, Chapter 19. http://tinyurl.com/mxw2j4l (accessed 20 November 2013) Public Health England (2013b) Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England Winter season (2012/13). http://tinyurl.com/n3fvjre (Accessed 11 November 2013) Qureshi AM, Hughes NJM, Murphy E, Primrose WR (2004) Factors influencing uptake of influenza vaccination among hospital-based health care workers. Occup Med (Lond) 54(3): 197-201 Royal College of Nursing (2004) Patient Group Directions: Guidance and information for nurses. http://tinyurl.com/ kv3n8xf (accessed 20 November 2013) Woodman C (2001) Promoting uptake of influenza vaccination among healthcare workers: a randomized controlled trial. J Public Health Med 23(4): 346–8 World Health Organization (2005) WHO global influenza preparedness plan. The role of WHO and recommendations for national measures before and during pandemics. http://tinyurl. com/bdyme (accessed 20 November 2013)
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Key points
British Journal of Nursing, 2013, Vol 22, No 21
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Influenza is a highly contagious upper respiratory tract disease causing significant morbidity and mortality among high-risk groups. Immunization of frontline healthcare workers (HCWs) in the NHS is thought to be beneficial in reducing subclinical infection, staff sickness absences and protects patients. Each year Public Health England launches the Seasonal Flu Campaign to help reduce influenza transmission by reinforcing the message that it is vital that frontline HCWs get vaccinated. Public Health produces figures on frontline workers who have been vaccinated annually. The 2011/2012 campaign showed uptake figures of the influenza vaccine was averaging 44.6% nationally. The efforts of an NHS trust to increase staff uptake of the annual seasonal flu vaccination programme has been highly commended as it achieved an impressive 68.7% uptake against a target of 70%. This article shows how the trust worked hard to improve uptake on flu vaccinations for HCWs during the 2012/2013 flu season. Recognised as a Top Improver by NHS Employers (2013) for vaccination uptake, the Trust identifies how measures can be adopted to improve vaccination rates and what barriers can prevent total compliance. High rates of HCW vaccination can benefit staff, patients and the communities within which they work and live. Key words: Top Improver ■ Influenza ■ Vaccination ■ Flu Campaign ■ Healthcare workers
I
nfluenza is caused by a virus, which was first identified in 1933. Influenza is a highly contagious upper respiratory tract disease causing significant morbidity and mortality in the elderly and among other highrisk groups. Symptoms include headache, fever, cough, sore throat, aching muscles and joints. There is a wide spectrum of illness ranging from minor symptoms through to pneumonia and death (Apisarnthanarak et al, 2004). The flu virus is highly contagious and easily passed from person to person when an infected person coughs or sneezes. Transmission can also occur by touching a surface contaminated with respiratory secretions and then putting the fingers in the mouth or nose or near the eyes (Bridges et al, 2003). The flu virus
Ann-Marie Aziz is Clinical Lead: Infection Prevention and Control, Pennine Care NHS Foundation Trust Accepted for publication: November 2013
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can live on a hard surface for up to 24 hours and a soft surface for around 20 minutes. The incubation period (the period between infection and the appearance of symptoms) is about 2–3 days. Although the virus has been detected before symptoms appear, adults are usually considered infectious once appear and for 3-5 days afterwards (Flahault, 2006). This period is longer in children.
Recommendations for the use of the vaccines Public Health England has updated ‘The Green Book’ in November 2013. The Green Book has the latest information on vaccines and vaccination procedures for all the vaccinepreventable infectious diseases that may occur in the UK. Chapter 19 is dedicated to influenza and includes material on the influenza immunisation programme (Public Health England, 2013a). The objective of the programme is to protect those who are most at risk of serious illness or death should they develop influenza and to reduce transmission of the infection, thereby contributing to the protection of vulnerable patients who may
have a suboptimal response to their own immunisations (Public Health England, 2013a). To facilitate this, general practitioners are required to proactively identify all those for whom influenza immunisations are indicated and to compile a register of those patients for whom influenza immunisation is recommended. Sufficient vaccine can then be ordered in advance and patients can be invited to planned immunisation sessions or appointments. Given that some influenza vaccines are restricted for use in particular age groups, the summaries of product characteristics (SPCs) for individual products should always be referred to when ordering vaccines to ensure that they can be given appropriately to particular patient age groups. Patients should be advised that many other organisms cause respiratory infections similar to influenza during the influenza season, e.g. the common cold and respiratory syncytial virus. Influenza vaccine will not protect against these diseases. Influenza vaccine should be offered, ideally before influenza viruses start to circulate to: ■■ All those aged 65 years or older, to include all those aged 65 years on or before 31 March 2014 (born on or before 31 March 1949) ■■ All children aged 2 years or 3 years, but not 4 years or older on or before the 1 September 2013 (date of birth on or after 2 September 2009 and on or before 1 September 2011) ■■ All those aged 6 months or older in the clinical risk groups shown in Table 1 (The Green Book, Chapter 19, Public Health England, 2013a).
Influenza vaccination for health care workers Frontline healthcare workers (HCWs) involved in direct patient care are encouraged to receive annually the seasonal influenza vaccination to protect themselves and their patients from influenza (Department of Health (DH), 2012a) It is difficult to avoid infection if there is an epidemic. Keeping away from crowded places
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Abstract
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Clinical risk groups
Examples (decision based on clinical judgement)
Chronic respiratory disease
Chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema; bronchiectasis, cystic fibrosis, interstitial lung fibrosis, pneumoconiosis and bronchopulmonary dysplasia (BPD) Asthma - with disease which requires continuous or repeated use of inhaled or systemic steroids or with previous exacerbations requiring hospital admission Children who have previously been admitted to hospital for lower respiratory tract disease
Chronic heart disease
Congenital heart disease Hypertension with cardiac complications Chronic heart failure Chronic heart failure Individuals requiring regular medication and/or follow-up for ischaemic heart disease
Chronic kidney disease
Chronic renal failure Nephrotic syndrome Renal transplantation
Chronic liver disease
Cirrhosis Biliary atresia Chronic hepatitis
Chronic neurological disease
Stroke Transient ischaemic attack (TIA)
Diabetes
Type 1 diabetes Type 2 diabetes requiring insulin or oral hypoglycaemic drugs Diet-controlled diabetes
Immunosuppression
Immunosupression due to disease or treatment Patients undergoing chemotherapy leading to immunosuppression Asplenia or splenic dysfunction HIV infection Individuals treated with, or likely to be treated with, systemic steroids for more than a month at a dose equivalent to prednisolone at 20 mg or more per day (any age) or, for children under 20 kg, a dose of 1 mg or more per kg per day Some immunocompromised patients may have a suboptimal immunological response to the vaccine
Asplenia or dysfunction of the spleen
This also includes conditions such as homozygous sickle cell disease and coeliac syndrome that may lead to splenic dysfunction
Pregnancy
All pregnant women should receive the trivalent seasonal influenza vaccine
Source: The Green Book, Chapter 19, Public Health England, 2013a
can reduce the risk of becoming infected and spreading it to others. A previous flu infection or vaccination will not necessarily provide protection against further infections because the virus is continually changing genetically and different subtypes circulate each winter. The viruses that cause flu frequently change, so any immunity produced by the flu shot will possibly decrease in the year after vaccination, people in high-risk groups should be vaccinated every year (Woodman, 2001). The best time to be vaccinated is between late September and early November, ready for the winter (World Health Organization, 2005).
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healthy people can develop more serious consequences and can require hospitalisation ■■ Patients: staff incubating or even suffering from flu can unintentionally pass this on to patients they are looking after. If the patients are ill, elderly or suffering from a variety of chronic conditions this can lead to serious illness and even death (Qureshi et al, 2004) ■■ Service continuity: if large numbers of staff require a week off work with flu, the service’s ability to keep looking after ill patients is severely curtailed with the likelihood of ward closures and cancelled clinics.
The Influenza Campaign The 2012/2013 Seasonal Flu Campaign (DH, 2012) was a campaign launched to help reduce the spread of cold, flu and other viruses. The campaign sets about reducing influenza transmission by reinforcing the message that it is vital that frontline HCWs get vaccinated. It promotes the message that people should cover their nose and mouth when they cough and sneeze, preferably with a tissue, and wash their hands afterwards. The campaign includes widespread ambient advertising promoting CATCH IT, BIN IT, KILL IT, appearing in health settings, on buses, trains and tubes and in offices and major shopping centres, reminding people how to avoid spreading germs when they sneeze and cough. Public Health England produces figures on frontline workers who have been vaccinated annually. The 2012/2013 campaign showed uptake figures of the influenza vaccine was averaging 45.6%, this compared with 44.6% in 2011/12 (Figure 1). Figure 2 shows the highest seasonal influenza vaccine uptake was among GP practice nurses (60.6%) and the lowest seasonal influenza vaccine uptake was among qualified nurses (excluding GP practice nurses) (40.1%). Figure 3 shows uptake for each survey month.
Rationale for vaccination
Vaccination uptake
Immunization of HCWs is thought to be beneficial in reducing in subclinical infection and reducing the level of sickness absences and effective in reducing nosocomial infections among elderly patients at risk (Carman et al, 2000; Hayward et al, 2006). It is important that the benefits of flu vaccination are communicated to all staff. The potential consequences of getting influenza due to not being immunised are: ■■ Personal: influenza is not a minor illness even in normally fit people. It makes people feel extremely unwell for 2–3 days and full recovery normally takes a week. Even fit and
The 2012/2013-influenza season has seen an increase in uptake of seasonal influenza vaccine among HCWs in the NHS. NHS frontline workers have achieved an impressive 45.6% uptake of the flu vaccination during last year’s campaign. This was against the national target of 70% for vaccinating frontline workers (DH, 2012).
How was the influenza vaccination uptake achieved? Low uptake of seasonal flu vaccination by HCWs continues to be an issue in the NHS (Public Health England, 2013b). While
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Table 1. Clinical risk groups who should receive the influenza immunisation
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clinical focus
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1. Planning delivery Vaccination clinics should, as far as possible, be arranged at the place of work and should include clinics during early, late and night shifts, at convenient areas throughout the Trust. Clinics were run efficiently with administrative support to deal with paperwork, to manage staff and data collection. This resulted in staff having quick, easy access to the vaccine. Dropin clinics were also made available for staff unable to make their designated appointment
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Seasonal influenza vaccine uptake in Healthare Workers (HCWs) in England by strategic health authority in 2012/13 compared to 2011/12 60 55
58.9 54.9
n 2011/12 vaccine uptake (%) n 2012/13 vaccine uptake (%)
56.1 53.3
52.8
50
47.6
45
49.1 46.1 41.9
40
41.7
40.2
44.5
43.7
42.7
36.0
35
37.8
39.0
39.6 37.6
38.7
30 25 20 15 10 5 0
North East
North West Yorkshire & The Humber
East Midlands
West Midlands
East of England
London
South East Coast
South Central
South West
Strategic Health Authority (SHA)
Figure 1. Seasonal influenza vaccine uptake amongst frontline HCWs by SHA in England Winter season 2012/13 (Public Health England, 2013b).
Seasonal influenza vaccine uptake in Healthcare Workers (HCWs) in England for 2012/13 compared to 2011/12 70
n 2011/12 vaccine uptake (%) n 2012/13 vaccine uptake (%)
65
60.6
60
58.1
55 Vaccine uptake %
vaccination of NHS staff remains voluntary, it is encouraged that staff are offered the vaccine in an accessible way, and all staff to seriously consider the benefits to themselves and their patients. Plans to improve vaccination rates by NHS Trusts are instigated annually and are part of a plan to help staff keep well during the winter. Many NHS Trusts commence influenza campaigns early to identify and bring together key members to attend influenza vaccination meetings and enlist flu champions who are members of staff who play a pivotal role in cascading the initiatives of the campaign. The Flu Campaign leader can be a member of staff within the Trust who has authority to arrange meetings and define leadership qualities to influence and create the importance of the campaign. Other key members that can be included in the campaign can be: ■■ Pharmacy staff ■■ Occupational health department ■■ Community district nurses ■■ Communications staff ■■ Infection prevention and control staff ■■ Staff Side (staff union representative) ■■ Flu Champions. Monthly meetings can be held by the group, with a schedule of agenda and previous minutes being sent to members in advance. Discussions at the meetings can incorporate lessons learnt from previous years, the plans for the flu season and how to promote awareness among HCWs (NHS Employers, 2012). Pharmacy staff discussed matters such as obtaining vaccines, quantity of vaccines and storage. It is important to involve staff side in the campaign. Not only do they provide valuable input to the planning of the campaign, they also help the influenza campaigners reach and communicate with many staff effectively. Their skills and networks help to provide effective partnership working and spread the message of the campaign. These, and many other reasons, can contribute to the success of campaigns and increase flu vaccination uptake. Other strategies that can contribute are:
50 45
51.2
52.7 48.8
44.6 45.6
44.4
46.0 42.5
45.2
44.7
48.0
49.1
40.2 41.1
39.3 40.1
40
50.8
46.3
35 30 25 20 15 10 5 0
All HCWs
All doctors (excl. GPs)
GPs only
All doctors Nurses (excl. GP practice (incl. GPs) GP practice nurses only nurses)
Staff group
Support to All nurses Allied clinical staff (incl. GP health practice professionals nurses)
Support to GPs
Figure 2. Seasonal influenza vaccine uptake amongst frontline HCWs in England Winter season 2012/13 (Public Health England, 2013b).
or who may have changed their mind. Options for delivery included: ■■ Setting up clinics in staff rooms or areas close to wards ■■ Setting up in the staff canteen ■■ Offering vaccinations out of hours ■■ Sending vaccinators to wards and departments to catch staff who are traditionally difficult to access ■■ Running clinics at places you are likely to find community-based staff ■■ Allowing staff to ‘drop in’ to a clinic at any
time that suits them peer vaccinators to vaccinate colleagues ■■ Training ward managers to vaccinate their own staff (or to swap with another manager and vaccinate their staff). ■■ Using
2. Setting targets and monitoring uptake Setting targets initially in the influenza campaign is important, as it gives vaccinators something to aim for and an incentive.
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Vaccine uptake %
40
30
All doctors (including GPs)
20
All qualified nurses (including GP practice nurses) All other professionally qualified clinical staff Total (all HCWs)
10
October
November
December
January
Survey month Figure 3. Healthcare workers vaccine uptake for each survey month (Public Health England, 2013b).
Vaccinating staff can be encouraged to aim to vaccinate 100% of front line staff. With the emphasis that particular priority should be given to staff working in areas where patients might be at particularly high risk (paediatric and care of elderly) (Anikeeva et al, 2009). Numbers of those staff vaccinated can be distributed monthly at influenza campaign meetings. Attendees at the meetings can review the numbers of staff vaccinate and address areas were numbers are low and what is working well at separate departments to aid in delivering good practice trust-wide.
b Get the ja safe
Get flu
Are you at risk from flu? Flu can be really serious. Getting a flu jab can protect you all winter. It’s free if you are pregnant, over 65 or have a health condition such as severe asthma, diabetes, a chest, heart, liver or kidney complaint, or lowered immunity.
It’s quick, safe and free. To book your jab, speak to your GP practice today.
jab The flu ve can’t gi you flu
www.nhs.uk/flu
Figure 4. Get the Flu Jab (NHS Employers, 2012)
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3. Vaccine supply The Seasonal Flu Plan is published annually and sets out arrangements for the ordering of vaccine for the annual seasonal flu programme. Pharmacy department completed the processing of orders in March, prior to the campaign starting. After calculations of staff on the frontline, a sufficient numbers of vaccines were ordered and deposited in various sites across NHS Trusts, awaiting distribution. Once orders were placed, suppliers were able to confirm their delivery schedule. Vaccine supply should not relinquish during the flu season, and if supplies are reducing in NHS Trusts, then correspondence can be made via the influenza campaign champions to ascertain were stocks could be accessed (DH, 2011).
4. Staff vaccination champions The flu champions should be nominated early on in the programme, and can provide support at meetings to other members of staff. Flu champions can be service managers and senior members of staff. It is necessary to ensure that all flu champions had the skills and knowledge to raise awareness and answer any questions staff may have in relation to the vaccine. The influenza meetings can highlight issues, such as staff choosing not to be vaccinated and if vaccination clinics are accessible. This can reinforce the importance of ensuring staff have access to up-to-date information about the risks and benefits of seasonal flu vaccine, and promoting vaccination as a positive choice. It has been shown that a 'Flu Champion' can have a positive influence on vaccination uptake (Health Protection Agency (HPA), 2012a).
5. Effective leadership Organisations where senior leaders support and promote the vaccination tend to have higher uptake rates than those that do not (Heimberger et al, 1995). NHS Trusts can improve the profile of the influenza campaign by taking photographs of their directors and other senior staff, such as consultants, being vaccinated. It is necessary that support from senior staff be gained early in the campaign as this can help to engage staff and give the effective leadership the campaign needs. Effective leadership helps to: ■■ Encourage immediate line managers to lead in encouraging their staff to take the vaccines and arranging for them to get vaccinated ■■ Encourage managers to promote positive messages and encourage staff to attend clinics ■■ Have senior clinicians acting as champions ■■ Have ‘respected’ staff publicly immunised ■■ Make sure the campaign was added to local Governance agendas.
6. Communications Communication is vital to promote uptake of the vaccine by staff to support local efforts and raise awareness of the vaccine. NHS trusts can send letters and flyers to staff inviting them to attend a specific clinic at/near to their place of work. The purpose of the invitations was not only to organise clinics, but also to encourage individuals to consider having the vaccine and to make a decision. To promote good levels of uptake, invitations can be sent out 2 weeks before commencement of the campaign to raise awareness within the organisation. Posters can be placed in prominent areas in NHS Trusts to promote flu vaccination (Figure 5). Emails can be sent to all staff on a weekly basis via NHS Trusts intranet giving information on the campaign and achievements towards the target of 70%.
7. Publicity and information materials It is important that influenza promotional campaigns deliver a marketing and awarenessraising crusade to promote uptake of the vaccine. This is to ensure that colleagues have enough time to display information and to prepare for the programme. The materials can be created in collaboration with NHS staff to get a consensus on their suitability. The materials created can be: ■■ An information leaflet containing key messages ■■ A poster with details of vaccination clinics
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Seasonal influenza vaccine uptake in Healthcare Workers (HCWs) by staff group for England 2012/2013 50
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clinical focus ■■ Dedicated
site on the Trust intranet where influenza material could be obtained In addition to these materials, the marketing campaign also included radio and PR activities with local and national media (NHS Employers, 2013a). A FAQ document should be available ahead of the start of the season that could be accessed on the HPA website via the trust intranet (2013). This document addresses the most common questions from professionals about vaccines, risk groups and seasonal flu. The Influenza chapter of the Immunisation against Infectious Disease (the ‘Green Book’) can also be made available, should staff wish to refer to it at any time (Public Health England, 2013a).
8. Education and training All NHS Trusts make great strides in reducing the spread of flu by vaccinating as many frontline staff as possible. However, as a local initiative it is necessary to provide education and training on influenza as the flu season approaches. Infection prevention and control training was revised to include necessary elements of containing respiratory infections (HPA, 2012b). Components of the training focused on: ■■ Containment of respiratory secretions (Catch it, Bin it, Kill it practices) ■■ Nurse patients with proven or suspected influenza in a side room ■■ Strict adherence to infection control principles and droplet precautions ■■ Use of personal protective equipment (PPE) ■■ Restriction of symptomatic workers and visitors ■■ Promoting staff vaccination.
2. Opening times of some clinics were restrictive This may have prevented staff attending. Therefore, future plans are required to ensure clinics are more accessible.
3. Vaccinating clinics and administration Influenza clinics that are well-organised can have good attendance. Pre-scheduled lists of staff for clinics ensure there are enough vaccines available enabling many more staff to be vaccinated. When clinics become busy it helps if arrangements are made to: ■■ Have a dedicated member of staff to complete the paperwork, while 1 or 2 nurses vaccinate ■■ Photocopy consent forms with the batch number on to save time ■■ Vaccinate those staff on lists first before drop-in staff – to avoid running out of vaccines. It was also necessary to ensure prospective
6. Lack of time to access information sent electronically
1. Staff not being released to attend clinics due to work pressures and commitments © 2013 MA Healthcare Ltd
A PGD is a written direction, signed by a doctor and agreed by a pharmacist, so a nurse can administer prescription-only medicines (POMs) to patients or staff using their own assessment of patient need, without necessarily referring back to a doctor for an individual prescription (Royal College of Nursing, 2004). The Seasonal Influenza Administration for Staff PGD helps to deliver vaccinations to staff. To complete the PGD, staff had to attend training on ‘Immunisation and Vaccination’, anaphylaxis training and basic life support. Staff also had to complete a PGD for adrenaline. Once this training was undertaken, it was requested their managers signed off the PGD and staff were then deemed competent to administer the flu vaccination.This laborious process can impede many staff from administrating the vaccination in their workplace, as it takes so long to complete. Plans to address these matters should be included in the preparatory planning phase of the influenza campaign.
It can be difficult to find the capacity to train extra potential vaccinators to help deliver the programme. Staff require annual updates to vaccinate under the PGD. This is a financial implication for training departments in the NHS, as it means more training and more resources. More staff training to administer the vaccination should be included in the influenza campaign plans.
NHS Trusts work hard to improve uptake on flu vaccinations for HCWs during the influenza season. However, there are still elements in the campaign that are more challenging than others. The factors that may impact on organisations not achieving its target of 70% influenza uptake are:
British Journal of Nursing, 2013, Vol 22, No 21
4. Patient Group Directive (PGD)
5. Staff not trained to give vaccination
Lessons learnt and recommendations
It is vital that managers understand the benefits of vaccination, not only so that they lead by example, but also so that they allow staff the time they need to get vaccinated. Off-duty rota in September to December are required to factor in and accommodate staff attending a vaccination clinic.
clinics had hand-washing facilities, a telephone and access to adrenaline and drug formularies. The issues with busy clinics should be addressed early in the campaign and suitable clinic venues should be nominated.
Figure 5. Jab-o-meter (NHS Employers, 2013b)
NHS staff can be very busy and may not have time to access information that is sent via emails about the flu campaign and vaccination clinics. It is important not to include too much text in the emails sent to staff, as they do not have the time to read them. Keeping the emails brief and to the point is key. Plans should be incorporated to include noncomputer based literature and a visual display of the campaign achievements so staff can see progress at a glance. The Flu Fighter Jab-ometer (Figure 5) is an effective info graphic that should inform and appeal to staff (NHS Employers, 2013b).
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n Influenza is a highly contagious upper respiratory tract disease that causes significant morbidity and mortality n The Seasonal Flu Campaign is launched annually to help reduce the spread of cold, flu and other viruses. n Influenza vaccination of frontline healthcare workers (HCWs) is required annually n There was an average 45.6% of frontline HCWs vaccinated in the 2012/2013 influenza campaign n It is necessary to commence the Influenza Campaign early n To overcome barriers and increase uptake, vaccination campaigns must be carefully designed and implemented taking account of the specific needs at each organisation
7. Myths that prevented staff being vaccinated Clinical staff can often believe things that simply are not true, and our job is to change this. Many HCWs who do not get vaccinated say it is because the vaccination makes them feel unwell or think it causes them to get the flu. Staff may not get the vaccination in case it results in them staying off work. Ensuring that staff can access the truth is vital. The use of the intranet page is useful to include, staff newsletters and magazines, emails and notice boards, as well as team meetings and briefings, to pass these messages on. ‘Myth busters’ should be included in all influenza campaigns to dispel any worries that staff may have when considering the vaccination.
staff to get vaccinated messages to email footers: ‘I’ve had my flu jab, have you?’ ■■ Send text messages to colleagues with work mobile phones ■■ Use screensavers and pop-ups on all trust computers ■■ Create competition between departments and give awards to teams with the highest uptake ■■ Use personal stories/experiences of staff in our campaign ■■ Sell the vaccine as a personal benefit rather than just a way of stopping people from being off sick ■■ Set up an email address for staff to submit their questions.
Recommendations
Conclusion
Although many NHS trusts do not achieve the target of 70% vaccination uptake, it is important that measures are incorporated into influenza campaigns to reach as many staff as possible. Bringing the vaccination to the staff is a major factor for vaccination of frontline staff success. NHS Trust induction programmes for new starters are a key time to access staff. Having the opportunity to talk to new staff is beneficial as information can be given about the vaccine and its benefits, and promote it as the norm before staff hear the wrong information from other sources. This can help with new entrants to NHS organisations. Other recommendations, for future planning are: ■■ Attach messages to payslips to encourage
NHS Trusts views seasonal influenza vaccination as a serious patient safety issue, given the impact of influenza infection. Having well-organised and well-planned influenza campaigns can improve vaccination rates and identify the barriers that can prevent total compliance. To overcome these barriers and increase uptake, vaccination campaigns must be carefully designed and implemented taking account of the specific needs at each trust. High rates of HCW vaccination will benefit patients, HCWs, their families and the communities within which they work and live. Many NHS Trusts have strived to improve vaccination rates for their front-line staff and this has helped to reduce the spread of infection to patients and
■■ Add
carers. However, we should not be complacent in our efforts to continually improve. Plans should always be in place to advance from BJN improving to out-performing. Conflict of interest: none Anikeeva O, Braunak-Mayer A, Rogers W (2009) Requiring Influenza Vaccination for Health Care Workers.Am J Public Health 99(1): 24–9 Apisarnthanarak A, Kitphati R, Thongphubeth K et al (2004) Atypical Avian Influenza (H5N1). Emerg Infect Dis 10(7): 1321–24 Bridges CB, Kuehnert KJ, Hall CB (2003) Transmission of influenza: implications for control in hospital settings. Clinical Infectious Diseases 37(8): 1094-1101 Carman WF, Elder AG, Wallace LA et al (2000) Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial. Lancet 355(9198): 93–7 Department of Health (2011) Accessing the flu vaccine strategic reserve in England. http://tinyurl.com/lwpafl8 (Accessed 20 November 2013) Department of Health (2012) Seasonal flu plan. Winter 2012/13. http://tinyurl.com/cokb4rb (Accessed 11 November 2013) Flahault A, Vergu E, Coudeville L, Grais RF (2006) Strategies for containing a global influenza pandemic. Vaccine. 24(446): 6751-5 Hayward et al (2006) Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 333(7581): 1241-7 Health Protection Agency (2012a) Increasing influenza immunisation uptake in pregnant women. http://tinyurl.com/ kpgas8p (accessed 20 November 2013) Health Protection Agency (2012b) Infection control precautions to minimise transmission of respiratory tract infections (RTIs) in the healthcare setting. http://tinyurl.com/ktyuz8q (accessed 20 November 2013) Health Protection Agency (2013) Frequently asked questions on influenza. http://tinyurl.com/mpj5r2x (accessed 20 November 2013) Heimberger T, Chang H, Shaikh M et al (1995) Knowledge and attitudes of healthcare workers about influenza: why are they not getting vaccinated? Infect Control Hosp Epidemiol 16(7): 412-5 NHS Employers (2012) Running your flu fighter campaign. http://tinyurl.com/p8jra56 (accessed 20 November 2013) NHS Employers (2013a) Flu Fighter Campaign- Materials. http://tinyurl.com/lgfafe9 (accessed 20 November 2013) NHS Employers (2013b) Use the Jab-o-meter in your local campaign. http://tinyurl.com/kyvceqs (Accessed 20 November 2013) Public Health England (2013a) The Green Book, Chapter 19. http://tinyurl.com/mxw2j4l (accessed 20 November 2013) Public Health England (2013b) Seasonal influenza vaccine uptake amongst frontline healthcare workers (HCWs) in England Winter season (2012/13). http://tinyurl.com/n3fvjre (Accessed 11 November 2013) Qureshi AM, Hughes NJM, Murphy E, Primrose WR (2004) Factors influencing uptake of influenza vaccination among hospital-based health care workers. Occup Med (Lond) 54(3): 197-201 Royal College of Nursing (2004) Patient Group Directions: Guidance and information for nurses. http://tinyurl.com/ kv3n8xf (accessed 20 November 2013) Woodman C (2001) Promoting uptake of influenza vaccination among healthcare workers: a randomized controlled trial. J Public Health Med 23(4): 346–8 World Health Organization (2005) WHO global influenza preparedness plan. The role of WHO and recommendations for national measures before and during pandemics. http://tinyurl. com/bdyme (accessed 20 November 2013)
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Key points
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