Joint Commission and Influenza Vaccination: IC.02.04.01

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Joint Commission approves of this blog

The Joint Commission has just released proposed requirements addressing influenza vaccination of staff and licensed independent practitioners. Revisions to current requirements are proposed for Hospital, Critical Access Hospital, and Long Term Care accreditation programs with new requirements proposed for Ambulatory Care, Behavioral Health Care, Home Care, Laboratory, Medicare Based Long Term Care, and Office-Based Surgery accreditation programs.  Comments will be gathered until May 17, 2011.

You can review the proposed standards and leave comments on the JC site here.

For the Hospital Accreditation Program IC.02.04.01, elements 1-3 remain the same, elements 4 and 5 have been revised and elements 6-9 have been added. The new text is bolded below and the revised elements are:

1. The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff

2. The hospital educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. (See also HR.01.04.01, EP 4)

3. The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff.

4. The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination.

4. The hospital includes in its infection control plan the goal of improving influenza vaccination rates. (For more information, refer to Standard IC.01.04.01)

5. The hospital takes steps to increase influenza vaccination rates.

5. The hospital sets incremental influenza vaccination goals, consistent with achieving the 90% rate established in the national influenza initiatives for 2020.

6. The hospital develops a written description of the methodology used to determine influenza vaccination rates. All hospital staff and licensed independent practitioners are to be included in the methodology for determining the influenza vaccination rates. (See also IC.02.04.01, EP 1)

7. The hospital evaluates the reasons given by staff and licensed independent practitioners for declining the influenza vaccination at least annually.

8. The hospital improves its vaccination rates according to its established goals and at least annually. (For more information, refer to Standards PI.02.01.01 and PI.03.01.01)

9. The hospital provides influenza vaccination rate data to key stakeholders including leaders, licensed independent practitioners, nursing staff, and other staff at least annually.

Flu vaccine breakthrough

Influenza virus, A/Hong Kong/1/68

Yesterday, when commenting on Bill Gates' vaccine efforts, I wrote that a key breakthrough might be "an influenza vaccine that targets a conserved region of the virus, which would eliminate the need for costly annual vaccinations."  As if on cue...

The Guardian reports of an influenza vaccine breakthrough out of Oxford University. The new vaccine, developed by Dr Sarah Gilbert's team, targets proteins inside the flu virus that are common across all strains. The two proteins, Nucleoprotein and matrix protein 1, are more than 90% conserved across all influenza A strains and less liable to change over time.

In their initial human trial of 11 healthy vaccinated people and 11 non-vaccinated people, they exposed them to what I think is A/Wisconsin/67/2005 (H3N2). Fewer vaccinated people got the flu and vaccinated people had more T-cells and more activated T-cells. We will have to wait a bit for more details, since they have just submitted the paper for publication. Interesting that the Guardian is reporting this before a a medical journal. Given how dysfunctional the peer-review process is these days (STAR-ICU trial anyone?), I don't blame them for communicating the results in this time-efficient manner.

You can read about the initial vaccine creation and phase 1 safety trial of the Modified Vaccinia virus Ankara vector encoding nucleoprotein and matrix protein 1 in the January 1st CID.

Guardian article by Alok Jha

Berthoud et al Clin Infect Dis, January 1, 2011

H1N1 Flu Deaths in the UK on the rise

Per a government report in the BBC and other UK papers, there have been 39 deaths from the flu this winter with 36 confirmed as H1N1-related while the other three were caused by influenza B.  Unlike here in the US, the UK vaccination committee does not recommend a flu "jab" for healthy children less than 5 and other children ages 5 to 15.  All but one of the deaths occurred in people <65yo. Around 20% of all ICU beds in England are now filled with confirmed or suspected influenza patients.

Health Secretary Andrew Lansley said "the people we would wish to vaccinate are people in at-risk groups and over 65s who can be contacted via their GP." Which makes some sense since 23/38 deaths (one patients data wasn't available yet) were from high-risk groups. However, that still leaves 40% of patients without any risk factors. Since there is no vaccine shortage, I wonder why they aren't broadening their vaccine strategy to include younger children. As it is, only 23% of currently eligible children <5 get vaccinated.

The H1N1 virus continues to attack younger children and not older adults. In English children <4yo, the influenza incidence is 184 cases/100,000 while it is only 36 cases/100,000 in those >65yo. An epidemic is defined as an incidence >200 cases/100,000.  Seems like rapid vaccination of children might be a good idea, particularly when you look at the graph below showing 2010-2011 as an active year, similar to the spring of 2008-2009 season when H1N1 began.  If H1N1 vaccine was available in spring 2009, I bet they would have promoted it more than they are promoting the vaccine now.

Oh, Happy New Year!

BBC report (12/30/2010)
Guardian report (1/1/2011)

UK Health Protection Agency Epidemiological Report 30 December 2010

ILI Activity with 2010-11 in red  - taken from UK HPA report (link above)

Prior seasonal influenza infections protective against 2009 Pandemic flu (if you're a ferret)

Looking back at the 2009 flu season, I realize how calm it is now compared to then.  I hope it stays that way!  In that pandemic, the attack rate was 50% in young populations compared to perhaps 10% in adults.  Why would this be the case? Serologic analysis showed little cross-reactivity between recent seasonal influenza A(H1N1) viruses and pandemic A(H1N1). The authors of a recent JID paper postulated that the lower attack rate in adults could result from multiple past exposures to viruses with similar B epitopes or since there is conservation of T cell epitopes between pandemic H1N1 and seasonal influenza A, then cellular immunity may also reduce disease severity. There's also the fact that adults responded to a single dose of pandemic H1N1 vaccine, while children did not, suggesting that past exposure to seasonal strains is important.

To examine the role of prior immune reponses in seasonal influenza on exposure to pandemic H1N1, Laurie et al. in the Oct 1 JID, studied the impact of one or two prior infections in a ferret model.  The found that a single prior infection with a seasonal influenza A virus, A/Fukushima/141/2006 (H1N1) or A/Panama/2007/1999 (H3N2), reduced the duration of shedding following challenge with 2009 pandemic H1N1, but not reduce the infection rate nor did it reduce the transmission to other ferrets.

The authors then tested whether two prior infections with seasonal influenza was protective against pandemic H1N1.  They determined that infection with seasonal A(H1N1) followed by A(H3N2) reduced the infection rate along with the amount and duration of shedding in ferrets challenged with pandemic A(H1N1). Interestingly, no virus was transmitted to other ferrets, nor did the exposed naïve ferrets experience seroconversion to pandemic flu.

Good news, if you're a ferret.

Laurie KL, et al JID, October 1, 2010.

Why I took the job? Low HAIs and high flu vaccine compliance!

Dr. Churchwell

Delaware's only children's hospital, Alfred I. duPont Hospital for Children, just announced that Dr. Kevin Churchwell will become chief executive officer in December.  I'm not sure even why I read the article, but what caught my eye was why he said he took the job:

Churchwell said the new (renovation) project was one issue that factored into accepting the job. He also was impressed with the quality of care delivered at duPont, which has low hospital-infection rates compared with other local and national hospitals. It also has high vaccination rates for the flu among its health care workers.

"They have a great safety infrastructure," Churchwell said. "A.I. is a leader in that, and they need to step out and teach other hospitals how it's done. That will make a big difference."

Something is up. Not only is it great that a CEO has HAIs as a major priority, which is hopefully becoming more common, but also that he selected the job based on the quality and safety of the hospital.  Perhaps it's because he's a pediatric critical care doc. Either way, it's pretty cool.


Delaware online announcement

Healthcare worker vaccination programs: what works?

There is a new study out in ICHE by Tom Talbot and colleagues that looked at which factors of an influenza vaccination program were associated with a higher proportion of healthcare workers being vaccinated for seasonal influenza. The survey was completed during June 2008 and looked at programs in place during the 2007-2008 influenza season at 50 hospitals within the 78-hospital University HeathSystem Consortium (UHC) Benchmarking Program. The proportion vaccinated was the same whether or not hospitals required a signed declination from refusers. Factors association with higher compliance were weekend provision of vaccine, train-the trainer programs, report of vaccination rates to administrators or to the board of trustees, a letter sent to employees emphasizing the importance of vaccination, and any form of visible leadership support. Sadly, the median compliance was 55% and ranged from 26% to 81%. Perhaps I should have titled my post, "what didn't work" because it's hard to say anything really worked with compliance this low.

Herd Immunity in Influenza

Mark Loeb and colleagues have produced another fine study. They report in JAMA the results of a cluster-randomized trial where they vaccinated children aged 3-15 in 49 small communities in rural Canada. Children were vaccinated with either inactivated trivalent influenza vaccine or hepatitis A vaccine as a control. Confirmed influenza (RT-PCR) was 61% lower in non-recipients in the communities where children were vaccinated (3.1%) compared to non-recipients in unvaccinated communities (7.6%). Their main conclusion was that "a significant herd immunity effect can be achieved when the uptake of vaccine is approximately 80% in clusters in which children and adolescents aged 3 to 15 years are immunized." One note: this study was completed during the 2008-2009 season.