Pa Patient Saf Advis 2013 Dec;10(4):137-9.
Update: Are Influenza, Pneumonia, and Vaccination Rates Improving in Nursing Home Residents?
Infectious Diseases; Gerontology
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Author

Sharon M. Bradley, RN, CIC
Senior Infection Prevention Analyst
Pennsylvania Patient Safety Authority

Influenza and Pneumococcal Vaccination Data

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.

Table 1. Nursing Home Respiratory Tract Infection Pooled Mean Rates, as Reported to the Pennsylvania Patient Safety Authority, 2009 to 2012
YearLower Respiratory Tract Infections (I.E., Pneumonia, Bronchitis,
Tracheobronchitis)
Influenza-like IllnessesOverall Respiratory Tract Infections*
No. of
Nursing
Homes Reporting
Pooled Infection Rate (95% CI)No. of
Nursing
Homes
Reporting
Pooled Infection Rate (95% CI)No. of
Nursing
Homes
Reporting
Pooled Infection Rate (95% CI)
2009NA0.45 (0.44 to 0.46)NA0.01 (0.01 to 0.01)NA0.46 (0.44 to 0.47)
20104840.44 (0.43 to 0.45)420.00 (0.00 to 0.01)4840.44 (0.43 to 0.45)
20115620.43 (0.42 to 0.44)1210.01 (0.01 to 0.01)5650.44 (0.43 to 0.45)
20124920.42 (0.42 to 0.43)650.01 (0.01 to 0.01)4940.43 (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 influenza-like 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.


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 illness and death in nursing home residents.3

A previous Pennsylvania Patient Safety Advisory article, “Increasing Influenza and Pneumonia 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 pneumococcal 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 Healthcare 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 workers 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 season, 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 seasons. See Table 2.

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)
Overall64 (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 office62 (658)68 (747)73 (636)
Other clinical setting52 (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


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.

CDC reports 96.5% coverage among US healthcare workers who had an employer requirement for vaccination.9 In the absence of requirements, increased vaccination coverage was associated with employers offering vaccination on-site, free of charge, and on multiple days.9

Strategies for Improving Vaccine Uptake

Nursing homes may improve their staff and resident vaccination rates and decrease LRTIs in their residents by following risk reduction strategies outlined in the Advisory articles “Increasing Influenza and Pneumonia Vaccination Rates in Long-Term Care” and “Strategies to Improve Outcomes in Nursing Home Residents with Modifiable Risk Factors for Respiratory Tract Infections,” including strategies to increase vaccine availability and acceptance.3,4 The articles are available on the Authority’s website at http://patientsafetyauthority.org.

The Pennsylvania Department of Health brought together a voluntary association of experts—including the Hospital and Healthsystem Association of Pennsylvania (HAP), the Authority, the Pennsylvania Immunization Coalition, and Pennsylvania hospitals and health systems that have achieved nearly universal vaccination coverage—to brainstorm how best to improve vaccine uptake among healthcare workers in Pennsylvania. The task force held seminars in May and June 2013 to showcase best practices and resources for improving influenza vaccination among healthcare personnel and will be working with healthcare facilities that are “considering or contemplating” making immunization mandatory within their facility to help them firm up their policy or develop program strategies.10 HAP has created a best-practices guide and toolkit that can be adapted to the long-term care setting. The toolkit is available at http://www.haponline.org/downloads/Universal_Flu_Immunization_Programs_for_Health_Care_Personnel-HAP_Quality_Best_Practice_Series_Sept2011.pdf.

Two of the priority goals noted in HHS’s National Action Plan to Prevent Health Care-Associated Infections: Road Map to Elimination are to (1) progress toward the Healthy People goal of having 90% of healthcare workers receive influenza vaccination by 2020, with 75% of healthcare workers in long-term care receiving influenza vaccination by 2015, and (2) achieve 85% vaccination coverage of eligible nursing home and skilled nursing facility residents for both influenza and pneumococcus within five years of the report’s publication in 2013.12

HHS plans to create web-based education and resources specifically targeting long-term care employers. These resources are being developed in response to the needs, barriers, and opportunities identified by stakeholders at a September 2011 workshop that addressed long-term care providers. The resources include a toolkit, planned for release by HHS during the 2013-14 influenza season, for increasing influenza vaccination of healthcare workers in long-term care settings.13

Notes

  1. Centers for Disease Control and Prevention. Ten leading causes of death and injury: causes of death by age group [online]. [cited 2013 Oct 1]. http://www.cdc.gov/injury/wisqars/leadingcauses.html
  2. Pennsylvania Patient Safety Authority. Healthcare-associated infections. Addendum H. In: 2012 annual report [online]. 2013 Apr 30 [cited 2013 Oct 1]. http://patientsafetyauthority.org/PatientSafetyAuthority/Documents/Annual%20Report%202012%20.pdf
  3. Bradley S. Strategies to improve outcomes in nursing home residents with modifiable risk factors for respiratory tract infections. Pa Patient Saf Advis [online] 2011 Dec [cited 2013 Oct 1]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/dec8(4)/Pages/131.aspx
  4. Increasing influenza and pneumonia vaccination rates in long-term care. Pa Patient Saf Advis [online] 2009 Dec [cited 2013 Oct 1]. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Dec6(4)/Pages/132.aspx 
  5. Agency for Healthcare Research and Quality. Pennsylvania nursing home care quality measures and metrics compared to all states. 2008 state snapshots [online]. [cited 2013 Oct 1]. http://statesnapshots.ahrq.gov/snaps08/meter_metrics.jspmenuId=14&state=PA&level=6&region=0&compGroup=N
  6. Agency for Healthcare Research and Quality. Pennsylvania nursing home care quality measures and metrics compared to all states. 2009 state snapshots [online]. [cited 2013 Oct 1]. http://statesnapshots.ahrq.gov/snaps09/meter_metrics.jsp?menuId=14&state=PA&level=6&region=0&compGroup=N
  7. Agency for Healthcare Research and Quality. Pennsylvania: nursing home quality measures and metrics compared to all states. 2011 state snapshots [online]. [cited 2013 Oct 1]. http://statesnapshots.ahrq.gov/snaps11/meter_metrics.jsp?menuId=14&state=PA&level=6&region=0&compGroup=N
  8. Centers for Disease Control and Prevention. Health care personnel flu vaccination Internet panel survey, United States, November 2012 [online]. 2013 Jul 17 [cited 2013 Oct 1]. http://www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm
  9. Centers for Disease Control and Prevention. Influenza vaccination coverage among health-care personnel--United States, 2012-13 season. MMWR Morb Mortal Wkly Rep 2013 Sep 27;62(38):781-6.
  10. The Pennsylvania Health Care Worker Vaccination Taskforce. About this resource [online]. [cited 2013 Oct 1]. http://pahcwfluvax.org/about
  11. Healthy People 2020. U.S. Department of Health and Human Services. Immunization and infectious diseases: objectives: IID-12.9 [online]. [cited 2013 Oct 1]. http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23
  12. US Department of Health and Human Services (HHS). Long-term care facilities. Chapter 8. In: US HHS. National action plan to prevent health care-associated infections: road map to elimination April 2013 [online]. [cited 2013 Oct 30]. http://www.hhs.gov/ash/initiatives/hai/actionplan/hai-action-plan-ltcf.pdf
  13. Stone N. HAI action plan metrics—LTCF update. Presented at: Road Map to Eliminate HAI: 2013 Action Plan Conference; 2013 Sep 25-26; Washington (DC).
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