By Karen O’Hara
While annual workplace flu vaccination campaigns are a routine occurrence for occupational health programs, they can become fraught with complexity if not well managed.
Challenges occupational health providers and their client companies may encounter include:
- finding and deploying enough qualified staff to administer large volumes of vaccinations in a short period of time across multiple locations
- addressing individual declinations for religious, medical or other reasons
- enforcing mandatory policies or encouraging voluntary compliance
- correcting misconceptions about vaccination health effects
- collecting, reporting and storing related records
Employers and their medical provider partners also may need to address conditions in the workplace such as reminding employees to practice good personal hygiene habits—staying home when ill, frequently disinfecting surfaces and implementing sound engineering controls.
The Occupational Health and Safety Administration’s (www.osha.gov) long-standing position for employers has been for influenza vaccination to be part of a comprehensive, multi-layered infection control program, not a stand-alone initiative. Under any circumstances, disease prevention in the workplace is one way employers can take an active role in promoting the health of their workforce and showing they are invested in the communities they serve.
Year-Round Effort Required
This year, National Influenza Vaccination Week is Dec. 7-13, but public health experts recommend startingworkplace flu campaigns earlier in the fall. Most occupational health programs start planning even sooner–– sometimes before the previous season concludes in March. Fixed-site clinics, flu shot days, health fairs, mobile medical units and roving vaccination carts are among preferred delivery methods. Successful on-site immunization programs typically emphasize the importance of convenience, education, communication and buy-in.
According to the Partnership for Prevention:
- Access and convenience are key; studies show scheduling flexibility improves compliance rates.
- In a study, companies that implemented an advertising campaign with one poster per 20 employees, three e-mail reminders, and if possible, one flyer per employee, experienced an 11 percent increase in compliance. (For more information, see Am J Prev Med. 2010;38(3):237-246.)
- Depending on workplace culture, communication can be accomplishedthrough print materials, online resources, face-to-face sessions and social media, including podcasts.
- Outreach efforts should be multidisciplinary and involve multiple departments, e.g., human resources, occupational health, safety, infection control, risk management, executive leadership and labor representation; collaboration increases the likelihood of employee engagement.
- Senior managers can be effective advocates by being vaccinated themselves and by becoming involved in educational campaigns.
- An on-site champion, such as an occupational health nurse, might administer injections and also help with logistics, such as finding a room to hold a flu clinic and distributing educational materials.
Programs Adapt To Customers
As the following four scenarios suggest, the ways in which provider-based occupational health programs and employee health departments manage flu season are as varied as the types of industries they serve. Many occupational health professionals report that with advanced planning and a strong promotional campaign they can administer an average of 40 to 50 shots per hour on-site using a single nurse or other qualified provider.
Scenario 1: Hospital-Affiliated Occupational Health Clinic
Employers in La Grange, GA, a rural community located southwest of Atlanta, is a market dominated by a Korean automotive manufacturer and spin-off companies that typically want a nurse to come on-site to administer the vaccine with “very little fanfare,”said Robert Carlson, director, West Georgia Worx (www.wghealth.org), a program of the West Georgia Health (WGH) system. The majority want WGH to bill their employees’ personal health insurance.
“Eight out of 10 companies in our area like the idea of billing the employee’s insurance; the other 20 percent say it’s a benevolent service,” Mr. Carlson said. “What has made a difference for us is the timelines associated with getting paid. Last season we administered vaccine in October and November and we didn’t get fully paid until April or May,” even though the charges were posted in a timely manner by WGH’s Physician Services Organization (PSO). West Georgia Worx uses a triplicate carbonless paper form that is completed by employees and that includes personal insurance information prior to flu shot day. After the on-site visit, one copy is delivered to the PSO billing department for processing. “The form is well designed, but it would be much better if we had an electronic record keeping system. We are not quite there yet,” Mr. Carlson said.
West Georgia Worx has ordered supplies for 1,000 client company vaccines this season. In 2013-14, Mr. Carlson estimates the health system made $8 to $9 per shot, taking into account insurance reimbursement and a standard $75 trip fee for nurses who go on-site. The program requires a minimum of 25 vaccinations to make the trip, unless a client company with a smaller workforce is located “just down the road” from the Worx clinic in La Grange.
Scenario 2: Freestanding Clinic
In Bakersfield, CA, Central Valley Occupational Medical Group, a freestanding practice, launches its flu outreach campaign in July and begins administering vaccine in September –about 80 percent on-site and the remainder in the clinic.
“That gives employers enough time to talk to their employees, pass out the educational materials and encourage [them] to be vaccinated,” said J.R. Carrera, director of marketing and business development at the Central Valley group. The educational materials come from the Centers for Disease Control and Prevention (CDC) and other public health sources.
The majority of Central Valley clients provide the vaccine to support prevention and demonstrate their commitment to employee well-being. They usually do not charge their employees’ insurance. “I think you get better participation if the employer covers the cost for the employees to reinforce the importance of having a healthy workforce,” Mr. Carrera said. “Going on-site is also extremely convenient. We are therefor two or three hours and the employees don’t have to go somewhere else and wait.”
Depending on the size of the client company, Central Valley may send two to five nurses on-site. Charges include mileage (the program serves a large geographic region dominated by agriculture, oil and gas production, and manufacturing) and hourly technician time. A number of Central Valley’s clients offer flu shots in conjunction with comprehensive fall health fairs, which also feature prizes, healthy snacks, and other incentives to participate. “They are very inventive. It’s not always just a flu clinic,” Mr. Carrera explained. In some instances, the clinic offers
on-site vaccination at a discount to attract or retain business.
“We’re a little more proactive with our accounts because it’s a competitive market,” he noted. To expedite the process, similar to West Georgia Worx, Central Valley provides consent forms to client companies in advance. Once completed, the forms are kept on file in the clinic.
Scenario 3: Accountable Care Organization And Its Occupational Health Program
Accountable Care Organization (ACO) in St. Joseph, MO., this will be the third year flu vaccination has been mandatory for its 4,200 employees, volunteers, and contractors. Those who decline must wear a mask during flu season. Last season the system reported a 99.5 percent compliance rate.
On a broader scale, the health system is looking for ways for Heartland Occupational Medicine, its occupational health program for client companies, to contribute to an AC delivery model that promotes “living life well;” this would include prevention programs for local employers, said Sherri Grider, R.N., occupational medicine team leader.
During flu season, Heartland Occupational Medicine may assign seven to 10 nurses to administer the vaccine at any given time. They find that employers in St. Joseph are receptive to but cost-conscious about prevention efforts.
“Here in the Midwest many employers are still struggling financially and have minimal budgets,” Ms. Grider said. “They know illness is tied to productivity, so they want to say ‘yes’ to vaccination, but if the decision is resident in HR or accounting, they will think first about the bottom line and second about prevention.”
The majority of Heartland’s client companies want vaccinations to be processed through private health insurance. Ms. Grider said it’s cumbersome because insurers prefer electronic submissions and don’t want to pay off a roster bill, while the program requires a roster bill for on-site work. Alternatively, employers may expect employees to pay out of pocket for the convenience of getting their flu shot at work, or they may simply pick up the tab each year because they believe it’s Important.
“The situation often depends on the individual at the company who is heading up these programs,” Ms. Grider said. “Some may have experienced flu and are prevention die-hards. Then I have the other employers who say they just can’t do it.”
When going on-site, Heartland Occupational Medicine strives to make it a seamless process by providing:
- on-site nurses who are familiar with the business and understand the work environment
- one lot number and the vaccine expiration date on consent forms at each location to simplify record-keeping
- all forms are to be completed in advance and on-site
- education and counseling, particularly for those who are fearful or have specific questions, such as vaccination during pregnancy, egg allergy, intranasal or mercury-free options
- reminders to wear suitable clothing to make it easy to administer the shot
- flexibility with regard to delivery locations, ranging from first-aid rooms at heavy manufacturing facilities to cafeterias, to office board rooms with multiple stations
“It’s important to communicate as much as you can in advance,” Ms. Grider advises. For example, if an employer wanted quadrivalent as opposed to trivalent vaccine this season, the program would need to know in advance.
Ms. Grider has observed that employers use a variety of incentives to encourage compliance food, prizes, and even the promise of a kiss from a long-time female manager who is a beloved character at the business. Whatever the incentive, “we find the best turnout occurs in companies where people are really thinking seriously about wellness,” Ms. Grider said.
“We do a lot of wellness screenings in October, which is challenging timewise in combination with the start of flu season, but it’s an important part of the mindset.” With respect to record keeping, Heartland Occupational Medicine is undergoing a transition to electronic medical records. In the future, Ms. Grider envisions taking tablet PCs on-site. In the meantime, clerical support is needed to help manage the paperwork.
Scenario 4:Hospital Employee Health Department
Similar to other large organizations, flu season represents a major undertaking at the Memorial Hermann Health System in Houston, TX, with over 35,000 mandatory vaccines administered internally, including 23,000 employees, 8,000 credentialed clinicians, 2,500 contractors, and 3,000 Volunteers, according to Danial Bravard, Workplace safety officer and system director, occupational health and safety, and his colleague, Cathy Floyd, a certified occupational health nurse and manager of the system’s occupational health department.
However, with mandatory participation in the vaccination program and a policy that requires non-vaccinated employees to wear masks during flu season, the system’s compliance rate has jumped from 60 percent to 99+ percent, with a corresponding decline in flu declinations.
Similar to Mosaic Life Care in St. Joseph, for the first time this year the system will be administering quadrivalent vaccine. “We had a really bad flu season in Texas last year and there were a number of deaths as a result,” Mr. Bravard said. “The strain we had in Houston last year hit young people especially hard while adults 45 and up were less affected by it.”
To accommodate federal reporting requirements, the system uses an electronic online registration form that employees complete beforehand and a badge scanner to verify compliance when the shot is administered. A centralized badge system helps improve overall security and enables the use of a database for analytical purposes.
Mr. Bravard and Ms. Floyd shared these “lessons learned:”
Offer Choices: Online registration and stationary flu clinics enable fast delivery. “We have also gone to great lengths to bring service directly to individuals, including roving carts and mobile flu clinics,” Mr. Bravard said. “We have more than 200 locations on the Gulf Coast. We don’t want to disrupt operations for people to get a shot. It’s much easier to make it mobile.” In addition, healthcare personnel, students, and instructors may get their shot elsewhere, such as at a drug store or campus clinic, as long as they provide proof of vaccination.
Planning and Promotions: Outreach begins at the end of August but planning begins in April. “It’s actually a year-round activity because it typically takes four months to regroup,” Ms. Floyd said. “We send save-the-date reminders to our marketing department in the summer. It’s a preemptive strike.” This year flu shots are being combined with a broader safety program and gift giveaways. “We are creating a fair-like atmosphere so there is excitement around the promotion,” Mr. Bravard said.
Staffing: Employee health dedicates 20 to 25 occupational health nurses to the effort, with additional support provided by medical assistants and LVNs. Temporary staffing may be used to provide clinic coverage at peak times. Mr. Bravard said his staff doubles in October.
Outcomes: The health system reviews lost work days associated with illness absence as a way to measure the success of its vaccination campaign. The vast majority of employees who miss work because of the flu are screened in the employee health department before returning to work.
“We also are trying to raise awareness about the impact of presenteeism and how to recognize flu symptoms. Caregivers have a tendency to ignore their own needs because they are so busy caring for others,” Ms. Floyd noted.
National Goals
The nation’s Healthy People 2020 (www.healthypeople.gov/2020/) flu vaccination target is 70 percent of working-age adults and 80 percent of the population as a whole. Among healthcare personnel, a population considered at particular risk of exposure, the goal is 90 percent. Vaccination coverage for healthcare workers was estimated at 67 percent during the 2011-12 season and 72 percent during the 2012-13 season.
The Partnership for Prevention (www.prevent.org/) reports 70 percent of the nation’s major employers offer flu shots, but only about 15 percent of the total U.S. population is immunized each year, a number far short of the Healthy People 2020 target.
Options This Season
Flu vaccines are designed to protect against viruses experts believe will be the most common in the upcoming season. The vaccine has traditionally offered protection against three flu viruses (trivalent). With the introduction of a vaccine containing a fourth antigen (quadrivalent) a few years ago, some manufacturers are phasing out the production of trivalent vaccines. Consequently, a growing number of employers, following the lead of many healthcare organizations, are expected to offer employees quadrivalent vaccines this season. The CDC does not recommend one over the other.
For 2014-15, a U.S.-licensed trivalent vaccine contains hemagglutinin (HA) derived from an A/California/7/2009 (H1N1)-like a virus, an A/Texas/50/2012 (H3N2)-like virus and a B/Massachusetts/2/2012-like (Yamagata lineage) virus. Quadrivalent vaccines contain these antigens as well as a B/Brisbane/60/2008-like (Victoria lineage) virus.
One consideration for employers is the price difference between quadrivalent and trivalent vaccines. The CDC’s online vaccine price comparison lists all vaccines on the market. In a cost-effectiveness analysis published in March 2014, researchers determined quadrivalent vaccination should be cost-effective at “conventional willingness-to-pay thresholds.” On average per influenza season, the inactivated quadrivalent vaccine was predicted to result in 30,251 fewer influenza cases, 3,512 fewer hospitalizations, 722 fewer deaths, 4,812 fewer life-years lost and 3,596 fewer quality-adjusted life years lost in comparison to the trivalent vaccine.
Reporting Requirements
Hospitals are required to report influenza vaccination rates among healthcare personnel to the CDC through the National Healthcare Safety Network, a surveillance system managed by the Division of Healthcare Quality Promotion. Data collected on vaccination rates and other safety-related initiatives are used for the development of practices that help minimize exposure risks in healthcare facilities and allow hospital quality and performance comparisons. Beginning this season, data on healthcare personnel working in inpatient units and outpatient departments will reportedly be combined on a single data entry screen. Hospitals must report:
- all influenza vaccinations administered at each affiliated location
- declinations
- determinations of a medical contraindication to influenza vaccination
- denominator data for personnel who work at least one day between Oct. 1 and March 31
The Joint Commission, which audits and accredits healthcare organizations, requires accredited facilities to establish an annual influenza vaccination program for licensed independent practitioners and staff. The standard requires hospitals and other accredited organizations to set incremental goals for meeting a 90 percent healthcare personnel coverage rate by 2020. The standard does not mandate influenza vaccination for staff as a condition of accreditation. However, the Joint Commission requires hospitals to “annually evaluate vaccination rates and the reasons given for declining the influenza vaccination” (Standard IC.02.04.01).
Mandatory V. Voluntary Vaccination
A growing number of organizations have adopted flu vaccination policies, with healthcare organizations at the fulcrum of a national debate about mandatory versus voluntary programs. Before implementing any type of vaccination policy, attorneys recommend consulting with legal counsel and contacting state or local public health officials for guidance. Attorneys advise employers to be prepared to demonstrate “reasonable business interest” whether vaccination is mandatory for all or selected employee groups or only strongly encouraged.
About The Author:
Karen O’Hara is Director of Marketing and Communications at WorkCare, a national occupational health services company. She is the former editor-in-chief of VISIONS and former senior vice president of RYAN Associates.
References And Resources:
- Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States,2014–15 Influenza Season, Aug. 15, 2014 /63(32); 691-697.
- Modeling the Effect of Different Vaccine Effectiveness Estimates on the Number of Vaccine-Prevented Influenza Associated Hospitalizations in Older Adults; A. Fry, et al.; Clinical Infectious Diseases Brief Report, Vol. 59, Aug. 1, 2014.
- Make it Your Business to Fight the Flu: Promoting the Seasonal Flu Vaccine, CDC toolkit.
- Give Productivity a Shot in the Arm: How Influenza Immunization Can Enhance Your Bottom Line; Partnership for Prevention presents the business case for worksite flu immunization.
- Myths and Facts About Flu and How Your Flu Immunization Tool- kit, Partnership for Prevention.
- Firing Employees Who Don’t Get Flu Shots: What Risks Do Hospitals Face? DrinkerBiddle law firm.
- Employer Guidance: Reducing Healthcare Workers’ Exposures to Seasonal Flu Virus, OSHA resource.
- Cultural Storytelling: Creating Narratives to Promote Flu Vaccination, National Adult and Influenza Immunization Summit, 2014.
