6. Immunization Programs
Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services (2019)
- ACIP = Advisory Committee on Immunization Practices
- CDC = Centers for Disease Control and Prevention
- CMS = Centers for Medicare & Medicaid Services
- HCP = Healthcare Personnel
- IIS = Immunization Information Systems
- NHSN = National Healthcare Safety Network
- OSHA = Occupational Safety and Health Administration
Immunization programs provide a set of services that ensure immunity to vaccine-preventable diseases, including documenting evidence of immunity, administering immunizations and re-immunizations, and record-keeping and reporting to state or local immunization information systems (IIS), also known as vaccine registries.[1,2] A program might support additional immunization services, such as pre-travel vaccines for HCP working abroad, or might arrange for such services with an external provider. Effective programs can:
- prevent vaccine-preventable diseases among HCP[1,3];
- prevent illness among patients1 and others, such as HCP family and household members, by reducing their risk of encountering infectious HCP;
- adhere to ACIP immunization recommendations for HCP[1,3]and federal, state, and local requirements;
- reduce the need for, and costs related to, reactive measures, including postexposure prophylaxis, use of sick leave, and work restrictions; and
- increase the efficiency of reporting HCP immunization information internally, as for performance measurement and quality improvement initiatives, and to external groups, such as payors and public health agencies.
The ACIP Vaccine Recommendations and Guidelines website provides criteria for evidence of immunity to vaccine-preventable diseases, immunization recommendations for HCP, and information on immunization program administration, such as instructions for storage and handling of immunobiologics, vaccine administration, documentation, and reporting of adverse events. Additional information on IIS, including contact information for state or local immunization programs through which links to IIS can be established, is available on the CDC Getting Started with IIS website.
Selected federal requirements and accreditation standards
The OSHA Bloodborne Pathogens standard requires that the hepatitis B vaccine be offered to all employees with occupational exposure to blood or other potentially infectious materials at the employer’s expense, and that the vaccine be available for postexposure management. In addition, the standard requires that employers inform employees about the vaccine’s efficacy, safety, method of administration, and the benefits of being vaccinated. Employees may refuse immunization but must sign a declination form that uses OSHA-prescribed language. Refer to the OSHA website Standard: 1910.1030. Bloodborne pathogensexternal icon for details. State and local requirements related to HCP immunizations and immunization programs vary by jurisdiction. In addition, payers—including CMS—and accreditation agencies may have requirements related to HCP immunization, such as reporting immunization coverage to NHSN and setting goals to improve immunization coverage.[6,7]
Barriers to immunization
Despite existing recommendations and requirements for immunization of HCP, HCP immunization coverage is suboptimal.[8,9] Barriers to vaccination vary depending on HCP subgroup and work setting. Barriers can include fear of adverse events from vaccination, including injection aversions; inconvenient access to vaccination (e.g., location, hours of service); lack of perceived need for vaccination (e.g., perception of low risk of acquiring a disease or low vaccine efficacy); and lack of leadership support for vaccination.[9-12]
Strategies for improving HCP immunization coverage
CDC and ACIP provide information on strategies to increase immunization coverage; see Table 11-1: “Recommendations regarding interventions to improve coverage of vaccines recommended for routine use among children, adolescents, and adults.” It has been shown that comprehensive immunization programs that include mandatory immunization policies reliably and substantially increase receipt of preplacement and annual vaccines.[13,14] Strategies other than mandatory policies that have been used in healthcare facilities to increase immunization coverage include[9-11,13-19]:
- Using organizational leaders as role models (e.g., visibly vaccinating institutional leaders to improve coverage among HCP under their leadership).
- Conducting education or organizational campaigns to promote awareness and knowledge about vaccines.
- Providing free access (i.e., no out-of-pocket expense to HCP) to vaccine.
- Providing incentives to encourage immunization, such as coupons for the hospital cafeteria, gift certificates, etc.
- Offering flexible worksite vaccine delivery (e.g., at multiple locations and times, via mobile carts).
- Obtaining signed declinations for vaccine from HCP with non-medical reasons to decline vaccination.
- Monitoring and reporting vaccination rates (e.g., monitoring vaccine coverage by facility ward to identify areas with low coverage for targeted interventions to increase vaccination rates).
For healthcare organization leaders and administrators
Set goals to achieve high rates of evidence of immunity to vaccine-preventable diseases recommended for healthcare personnel by the Advisory Committee on Immunization Practices (ACIP).
For occupational health services leaders and staff
Develop, review, and update when necessary immunization program policies and procedures that:
Adhere to Advisory Committee on Immunization Practices (ACIP) recommendations for immunizing healthcare personnel.
Indicate all preplacement, annual, and other job-related immunizations that healthcare personnel should receive.
Specify strategies to offer vaccines to healthcare personnel and to achieve high immunization coverage.
Specify strategies for gathering and reviewing information on why recommended immunizations are not administered to inform program quality improvement.
- Advisory Committee on Immunization Practices; Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011 Nov 25;60(RR-7):1-45.
- Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee. Centers for Disease Control and Prevention. Reviewed December 27, 2018. Accessed August 20, 2019.
- Schillie S, Murphy TV, Sawyer M, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep 2013 Dec 20;62(RR-10):1-19.
- Standard 1910.1030 – Toxic and Hazardous Substances, Bloodborne Pathogensexternal icon. Occupational Safety and Health Administration. Revised April 3, 2012. Accessed August 20, 2019.
- Conditions for Coverage (CfCs) & Conditions of Participation (CoPs)external icon. Centers for Medicare & Medicaid Services. Revised November 6, 2013. Accessed August 20, 2019.
- Standard IC.02.04.01 Influenza Vaccination for Licensed Independent Practitioners and Staff (HAP, CAH, LTCexternal icon). The Joint Commission. Published December 2, 2011. Accessed August 20, 2019.
- State Operations Manual Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitalspdf icon[PDF – 546 pages]external icon. Centers for Medicare & Medicaid Services, U.S. Dept. of Health and Human Services. Revised October 12, 2018. Accessed August 20, 2019.
- Williams WW, Lu P, O’Halloran A, et al. Surveillance of Vaccination Coverage among Adult Populations — United States, 2015. MMWR Surveill Summ. 2017;66(No. SS-11):1-28.
- Call to Action: Improving Healthcare Personnel Immunization Rates[PDF – 12 pages]external icon. National Foundation for Infectious Diseases. Published March 2018. Accessed August 20, 2019.
- Black CL, Yue X, Ball SW, et al. Influenza Vaccination Coverage Among Health Care Personnel–United States, 2014-15 Influenza Season. MMWR Morb Mortal Wkly Rep. 2015 Sep 18;64(36):993-9.
- Hollmeyer HG, Hayden F, Poland G, et al. Influenza vaccination of health care workers in hospitals—A review of studies on attitudes and predictors. Vaccine. 2009; 27(30):3935-3944.
- Tucker SJ, Poland GA, Jacobson RM. Requiring influenza vaccination for health care workers: the case for mandatory vaccination with informed declination. Am J Nurs. 2008 Feb;108(2):32-4.
- Greene MT, Fowler KE, Ratz D, et al. Changes in Influenza Vaccination Requirements for Health Care Personnel in US Hospitals. JAMA Network Open. 2018;1(2):e180143.
- Frederick J, Brown AC, Cummings DA, et al. Protecting Healthcare Personnel in Outpatient Settings: The Influence of Mandatory Versus Nonmandatory Influenza Vaccination Policies on Workplace Absenteeism During Multiple Respiratory Virus Seasons. Infect Control Hosp Epidemiol. 2018 Apr;39(4):452-461.
- Community Preventive Services Task Force. Worksite: Seasonal Influenza Vaccinations Using Interventions with On-Site, Free, Actively Promoted Vaccinations – Healthcare Workersexternal icon. Centers for Disease Control and Prevention. Published June 2008. Revised December 6, 2013. Updated August 14, 2019. Accessed August 20, 2019.
- Lam PP, Chambers LW, MacDougall DM, et al. Seasonal influenza vaccination campaigns for health care personnel: systematic review. CMAJ. 2010 Sep 7;182(12):E542-8.
- Leibu R, Maslow J. Effectiveness and acceptance of a health care-based mandatory vaccination program. J Occup Environ Med. 2015 Jan;57(1):58-61.
- Esolen LM, Kilheeney KL. A mandatory campaign to vaccinate health care workers against pertussis. Am J Infect Control. 2013 Aug;41(8):740-2.
- Hollmeyer H, Hayden F, Mounts A, et al. Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza Other Resp. 2013 Jul;7(4):604-21.