WASHINGTON, DC— Severe acute respiratory syndrome (SARS) swept across the globe in 2003 with a near 10% mortality rate. VA patients over the age of 65 were particularly vulnerable, and faced a 50% mortality rate. Since hospitals are prime vectors for the spread of disease if proper precautions aren’t taken, VA knew it had to do something to protect its inpatient population.
VA’s Office of Public Health and Environmental Hazards (OPHEH) put together a series of prevention measures centered around SARS to help make sure that, should the disease present in a VA facility, it would not easily spread. Once the threat of SARS passed, OPHEH staff realized that information on those prevention measures—most of them incredibly simple and applicable to other infectious diseases, especially influenza—were not available in an educational format for patients or staff.
“We’re talking all the basics, like covering your mouth when you cough, washing your hands, and cleaning your hands with a disinfectant,” OPHEH Senior Program Manager Troy Knighton told U.S. Medicine. “Clinicians know these things, and they have a set of standards for disinfection of their hands. But this basic information wasn’t available for our patients and the whole of our staff.”
A Campaign Based on Simple Solutions
Out of this realization grew Infection: Don’t Pass It On (IDPIO )—an ongoing campaign by VA’s public health staff to involve VA staff, veterans, and hospital visitors by developing and distributing education and communication materials on preventing the transmission of infection.
The campaign’s message includes promotion of hand hygiene; respiratory etiquette; correct use of personal protective equipment; and basic public health measures to prevent transmission of infection. In 2005, the same group began coordinating seasonal influenza efforts, including vaccine distribution. When the pandemic flu came to the US in 2009, they were significantly involved in VA’s pandemic preparedness and response.
The message that IDPIO promotes might seem like a simple one, but its success requires changing basic learned behavior ingrained since childhood. The campaign’s strategy involves identifying as many target audiences as possible and tweaking their message in specific ways to reach each of those audiences. “It’s very hard,” Knighton said. “When you take an educational perspective, we know that we have so many target audiences within the VA community and one size does not fit all. We have over 100 posters with different messages aimed at staff and patients, some with cartoons, some very serious, and all on the topics of hand and respiratory hygiene, flu, bathroom etiquette, etc.”
“Changing behavior isn’t easy to do,” added Janet Durfee, RN, VA’s acting chief consultant on public health. “But using a lot of different messages can help.”
Focusing on Seasonal Flu
A lot of the IDPIO coordinating team’s attention is focused on promoting the use of the seasonal flu vaccine to stop the spread of influenza. “We have very good data looking at vaccine rates. We know that one way to prevent influenza is to aggressively vaccinate our population,” Durfee said. “VA believes annual vaccination is the best option for controlling influenza, and that is supported when you look at the amount of vaccine we have ordered.” In 2009, VA ordered 700,000 doses. This year, they ordered 3.3 million doses.
Despite the agency’s investment in vaccination, it still depends on staff and patients choosing to get vaccinated. In 2009, IDPIO hired an outside contractor to conduct 40 focus groups—20 for patients and 20 for staff—throughout the country. “The feedback we got from that affirmed what a lot of the literature told us over the years and what we’ve heard informally about reasons staff and patients choose not to get vaccinated,” Knighton said. “It resulted in us understanding a little bit more that both staff and patients wanted to know more about flu and the vaccine itself. They had all heard the message they should get a flu shot, but they wanted to know why. ‘If I get a flu shot, how does that help me? How does that help my community?’”
The result of that feedback was 16 new posters and flyers—educational materials that described all of the positive reasons why flu vaccination is important and how influenza can affect people in the VA community, especially in community living centers, which contain the most vulnerable populations.
During the 2008-2009 influenza season, VA vaccinated 83% of its patients over 65 years of age—the patient population the CDC most strongly recommends get the vaccine. The national average was around 66%. VA’s vaccination rate for those patients 50 to 64 years of age was 69% compared to the national average of 40%. During the 2009-2010 season, VA rates were 82% for patients 65 and over. The national average has not been released yet.
Last season, 77% of VA’s healthcare personnel were vaccinated. The last year a national average was calculated for vaccination of healthcare personnel was in 2007, when the number was 49%. That year, VA vaccinated 65% of its healthcare staff.
IDPIO serves as a communications hub and information clearinghouse for VA on the topic of influenza. The group has identified local champions of infection prevention and flu prevention coordinators at facilities across the VA system who help IDPIO coordinate its efforts. “This is very much a collaborative effort between education specialists, communication folks, infection control experts, infectious disease subject matter experts, pharmacists, occupational health staff, nurses, and those that specialize in healthcare prevention efforts, too,” Knighton said. “And we have a very fluid and ongoing communication with field folk. Information flows through our office and into the field by working through all these collaborations and partnerships. I’ve heard several times that people appreciate knowing what office is in charge of the flu and whom they can contact to get information.”
New Season, New Challenges
This year poses a significant challenge for VA’s influenza prevention efforts. Each year CDC’s Advisory Committee on Immunization Practices issues a list of vaccination recommendations. In previous years, CDC recommended the targeting of high-risk groups, such as those over 65 and those with chronic illness. However, because the 2009 pandemic influenza seriously impacted even young, healthy adults, CDC has changed their recommendation to include vaccinating all people six months and older. “This is a whole new ballgame,” Knighton said.
“That’s a big shift in the targeted messages we’ve done before,” Durfee said. “IDPIO will need to start educational campaigns in the younger age groups.”
Another challenge for the coming year is the inclusion of the high-dose influenza vaccine in VA’s formulary. Containing the same antigens as the regular vaccine but in higher doses, the high-dose vaccine is targeted specifically for patients 65 and over.
“At this point, the dose is available to veterans, but we’re not mandating that veterans 65 and over get the dose,” Durfee said. “Studies show an increased antibody response to the high-dose flu vaccine, and we hypothesize that higher antibody response will provide greater protection, but the outcome remains to be seen if it does actually provide more protection.”
Knighton receives phone calls every week from clinicians with questions about the vaccine and influenza prevention—calls he is all too happy to take. “We consider it our ongoing challenge to help educate folks that still believe in some misperceptions about flu,” he said. “Each year we try to do something new and different in hopes that it will garner the attention of one of those folks reluctant to get their flu shot, or give the same message in a different way to healthcare staff and they will hear it and something will click.”