- Email: [email protected]
Hepatitis B vaccine programs give ICPs a shot in the arm Results of a national survey
Results of a national survey Linda J. Haneclk, RN, MS, CIC Nancy M. Iversen, BS Kelley A. Cwmd, PhD Geuia Lowe&erg, PhD Milwaukee and Kenosha, Wisconsin
In May 1982, at the Eighth Annual Educational Conference of the Association for Practitioners in Infection Control (APIC), the upcoming release of Heptavax-B (Merck Sharp & Dohme) was announced. Since then, on the basis of the number of doses of hepatitis B vaccine distributed, approximately 2.5 million persons have received hepatitis B vaccine in this country (Merck Sharp & Dohme market research data on file, February 1989). This article reports the results of a national survey of APIC practitioners on the administration of hepatitis B programs. METHODS
A survey, which was developed to determine the progress of hepatitis B vaccination programs after the 1982 release of Heptavax-B, was distributed at the Thirteenth Annual Educational Convention of the Association for Practitioners in Infection Control in May 1986 in Las Vegas, Nevada (Fig. 1). The study was conceived, designed, and administered by an APIC member who gave a small box of stationery to each participant in appreciation for participation in this effort. From Froedtert Memorial Lutheran Hospital, Milwaukee, University of Wisconsin-Parkside, Kenosha, and Humber, Mundie and McClary, Milwaukee. Financial support for survey printing provided by Merck Sharp & Dohme. Reprint requests: Linda J. Hanacik, RN, CIC, Nurse Epidemiologist, Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Ave., Milwaukee, WI 53226. 148
The survey contained nine questions that solicited 59 different responses from participants. Items were either multiple choice or short answer to be completed on the basis of the participants’ knowledge of their facility’s program at the time of the conference. Descriptive statistics were calculated with the use of the Statistical Package for the Social Sciences (SPSS).’ Further analyses included selected cross-tabulations and correlations. Because the investigators had no definite hypotheses about the number or the composition of factors, we chose to do a principal component factor analysis’ to determine the smallest number of factors needed to explain all the common variance in all of the questions. We used the Varimax selection criteria, that is, retaining factors with eigenvalue of 1 .O or greater, which~ ensured that we retained only factors that explained more variance than was explained simply by the component questions. Our factor analysis was enhanced by the use of a Varimax rotation,2 a process that leads to a clearer separation of factors by limiting the number of questions that have high correlations on a given factor. Questions that involved short essay responses were manually categorized and tabulated.
Of the 800 surveys distributed, 449 (56%) were returned (439 at the convention and 10 mailed in later). Demaphic data revealed that respondents were from 45 -states and the District of Columbia; states not included were
Volume 17 Number 3 June 1989
National survey of hepatitis B vaccine programs
Fig. 1. Hepatitis B program survey Directions: Please place an “x” in the box(es) that most closely 1. Do you work in a: 0 Hospital 0 Nursing home/extended 2. What is the estimated average patient census in your institution?
q Cl00
q
100-200
q
q
200-400
149
indicates your response. care facility?
>400
In which state is your institution located? 4. What is the population of the community in which your institution is located? 0 <10,000 q 10,000-39,000 0 40,000-100,000 q >100,000 5. The following is a list of populations at increased risk for hepatitis B. Please indicate which population(s) would routinely be cared for at your institution. 0 Homosexually active males 0 Male prisoners 0 Immigrants/refugees 0 Institutionalized mentally Cl Contacts of hepatitis B carriers 0 Staff of institution of 0 Hemodialysis patients mentally handicapped handicapped 0 IV drug users 0 Health care workers with frequent blood contact 6. Has your institution offered the hepatitis B vaccine to its employees? q Yes q No If yes, complete the remaining questions in No. 6. If no, skip to question No. 7. a. What year was the first dose of hepatitis B vaccine given?
3.
0 ‘82
q
‘83
0 ‘84
q
‘85
q
‘86
b. Personnel in are included Yes No N/A 0 0 0 0 0 0
c. d. e. f. g.
h. i, j.
k. I.
the following departments are considered at increased risk for hepatitis B. Please indicate which departments in your vaccination program. Yes No N/A Emergency room 0 0 q IV team Operating room 0 0 0 Clinic areas 0 q q Recovery room 0 0 0 Phlebotomists 0 0 0 Respiratory therapy 0 0 0 Labor and delivery Cl 0 0 Intensive care Other Cl •1 0 Dialysis 0 0 0 Code 4 team Estimate the percentage of employees at increased risk over total employees population. % Did your vaccination program offer special inservice presentations? 0 Yes q No If yes, were these mandatory? q Yes q No Did employees who received vaccine sign a consent form? q Yes 0 No 0 Unsure Did employees who refused the vaccine offer sign a refusal form? 0 No q Yes Cl Unsure In the list below are 9 common reasons why people do not accept vaccine. Please rate in order (1 = most common reason) for refusing. If female, concerns of pregnancy, or lactation? Newness of vaccine? (released in 1982) Concern of side effects? Personal convictions? Concern of AIDS? __ Didn’t feel you had enough exposure to hepatitis B to get vaccine? ___ Lack of knowledge concerning vaccine benefitslsafetyleff icacy? Cost to employee? Other? Who paid for vaccination program for increased risk employees? 0 100% institution Cl 100% employee q Co-pay Give your estimate of percentage of employees offered vaccine who received first dose. % Percent receiving third dose. % Rank in order (1 = most) department contributing the most amount of time on vaccine program. Infection control Personnel department Other ~ Employee health Hospital administration Did you have any personal responsibility for the program? 0 Yes q No In retrospect, to what degree were you satisfied with the vaccination program? 1 2 4 3 5 Very dissatisfied Very satisfied
Continued.
Amencan
1 SO Hanacik et al. Continued. m. In the next 3 years, 0 Expanding n. Have your employee 0 Yes If yes, how: o.
Do you
p.
What
Journal
INFECT!ON
do you see your vaccination program 0 Maintaining 0 Reducing i: Canceling health policies changed in regard to hepatitis B exposure 0 No
prophylaxis
as a result
of your
program?
_-___l_l._
feel that hepatitis B vaccination 0 Yes 0 No were the three aspects you liked
programs best
about
are cost
effective
in the long
run?
the program?
--
1)
Thank
you
for completing
this
survey.
If your
facility
did not have
a program,
respond
below.
7. If you did not have a vaccination program, was it due to any of the following? Please indicate responses in order of reason (1 = most common) Yes No Ranking order Lack of funds cl0 Lack of cooperation between departments q n Program too time-consuming no on Low hepatitis risks in your institution Fear of AIDS UC] Unknown short-term side effects on Unknown long-term side effects No employee health program E Waiting for synthetic vaccine on Other on 8. In the space below, describe the status with any difficulties or complicating factors which have
9. Whether or not your institution has considering a vaccination program?
Thank
01
CONX-301.
you
for completing
a hepatitis
B vaccination
program,
what
would
be your
either
influenced
professional
yes
or no and
your
advice
rank yes
program.
for sameone
this survey.
Arkansas, Delaware, Idaho, Mississippi, and South Dakota. The majority (95%) of infection control practitioners (ICPs) worked in hospitals; 3% worked in extended care facilities. More than 90% of respondents had active hepatitis B vaccination programs. On the basis of
average daily census a wide range of institutional sizes was reported: 17%, fewer than 100; 24%, 100-199; 32%, 200-399; and 27%, 400 or more patients per day. More than half (54%) of the facilities served communities with populations larger than 100,000, 26% were ins the
Volume
17 Number
3
June 1989
range of 40,000-99,999, 16% were in the range of lO,OOO-39,999, and only 4% represented communities with a population less than 10,000. The vast majority of ICPs (90%) estimated that fewer than half of the employees at their institutions were at increased risk for hepatitis B. Table 1 lists populations at increased risk that are routinely cared for by the respondents’ health care facilities. The survey data indicated that 90% of the ICPs who responded offered hepatitis B vaccine to their employees, with the majority of the first doses being offered in 1983 (29%) and 1984 (24%). Of the vaccine programs 83% offered special inservice presentations. Of these 32% were mandatory. A principal components factor analysis was done on the survey results. This kind of analysis examines the variance in the responses to the survey. Groups of items that share variance were identified as factors. This survey yielded eleven interpretable factors with eigenvalues greater than 1 .O. Some common elements were observed in these factors, which is not unusual for these kinds of analyses. To facilitate interpretations we grouped factors into four main categories. Category one (reasons for refusing hepatitis B vaccine) was composed solely of factor one and explained 10.9% of the variance. Items included in the questionnaire that contributed to this category were alternatives dealing with vaccine refusal (question No. 6g) (e.g., lack of vaccine knowledge concerning benefits, safety and efficacy, lack of sufficient blood exposure to warrant vaccine, newness of vaccine, concern for side effects, concern about acquired immunodeficiency syndrome [AIDS], pregnancy and lactation among women, personal convictions, costs to employees, and other concerns) and the involvement of hospital administrators and personnel departments as the major developers for hepatitis B vaccination programs in their health care facility (question No. 6j). The second category (high-risk departments to which vaccine was offered) (question No. 6b) summarized the data of departments within facilities and their level of participation within the programs. This grouped three of
National
survey of hepatitis
B vaccine
programs
151
Table 1. Number of persons surveyed who indicated that care was routinely given at their facility to specific high-risk populations Populatkm
at high
risk
Health care workers Intravenous drug users Patients receiving hemodialysis Contacts of hepatitis B carriers Homosexually active men Immigrants and refugees Institutionalized mentally handicapped persons Male prisoners Staff at institutions for the mentally handicapped
No.
(%I
364 287 265 260 247 175 121
(81)
99 76
(22)
w (59) (58) (55) (39) (27) (17)
the factors and explained 17% of the variance in survey responses. In health care institutions, on the basis of frequency of blood contact, personnel in certain departments were at increased risk for hepatitis B. In those facilities that included such departments, the percentage of respondents indicating inclusion of the department in the vaccine program were dialysis (99%), emergency room (980/o), operating room (98%), phlebotomy (98%), intensive care unit (96%), intravenous team (95%), recovery room (92%), labor and delivery (90%), code 4 team (83%), respiratory therapy (78%), and clinic areas (62%). The third category (successful programs) grouped items describing reasons for successful hepatitis B vaccination programs. It included four other factors and explained 18.8% of the variance. Items included in this category were use of signed consent/refusal form (question Nos. 6e and 6f), level of ICPs’ satisfaction (question No. 61), degree of compliance with first or third dose of vaccine (question No. 6i), whether ICPs contributed a high percentage of time if inservice programs were offered (question No. 6d) and if so, whether they were mandatory, and whether ICPs conducted the training programs (question No. 6k). The last category (expansion of program) grouped the remaining three factors and described the reasons for program expansion. This category accounted for 8.9% of the variance. Items included cost effectiveness of the pro-
0mer:can
IS2
Hanacik et al.
gram (question No. 60)~ plan for expansion during the subsequent 3 years (question No. 6m), employee health policy changes (question No. 6n), involvement of employee health department (question No. 6j), other departments’ contribution of time to the program (question No. 6j), high number of employees at risk for hepatitis B (question No. 6c), vaccine provided for code 4 team (question No. 6b), and employees’ belief that their length of exposure did not warrant vaccine (question No. 6g). In summary, four factors explained most of the variance in the answers to the survey questions: (1) the reasons for refusing hepatitis B vaccine, (2) high-risk departments to which vaccine was offered, (3) grouping items dealing with successful programs, and (4) the expansion of programs. Respondents ranked the departments according to their contribution of time on the vaccine program; 8 1% reported involvement by the ICP. The percentage of respondents who reported involvement of other departments were employee health service (71%), hospital administration (6%), personnel department (5%), and other departments (3.5%). A Likert scale was used to rate level of satisfaction with the vaccine programs: 17%, very satisfied; 24%‘ moderately satisfied; 30%, neither satisfied or dissatisfied; 13%, mildly dissatisfied; and 5%, very dissatisfied. Perhaps in part because of the high level of satisfaction with the hepatitis B vaccination programs, 36% of the survey respondents indicated that they planned to expand the program, 49% planned to maintain it, but a few planned to reduce (4%) or cancel (1%) it. Vaccine programs were also believed to be cost effective by 79% of all respondents. The next section of the survey solicited openended comments from ICPs about employee health policy changes, aspects of programs ICPs liked best, complicating factors, and the 1CP.s’ professional advice for future programs. Although not many comments were made about changes in employee health policies, decreases in antibody testing and prophylaxis medication administration were reported by 29 (11%) respondents, and a decrease in the use of hepatitis B immunoglobulin was seen in 27 (10%). Other responses tallied included recommendations to
INFECVOK
Journal
of
CONTROL
establish a protocol to check for protective antibodies after puncture wounds, 28 (lO%j; improved reporting and follow-up of’ puncture wounds, 12 (4%); and reduction of screening after vaccination, 13 (5%). The aspects the ICPs liked best about their programs were that they provided an educational opportunity for employees to learn about hepatitis (26%), the protection and safety the vaccine provides (22%), facility-sponsored program to employees at increased risk for hepatitis B (18%), the need to change and update their puncture wound protocols (1 I%), and the cooperation of the hospital administrators, physicians, and department managers (7%). Other less frequently described comments included the cost effectiveness of the program (4%), the opportunity to demonstrate a “we care” attitude toward employees (3%), and the ease of vaccine program implementation (2%). Complicating factors that interfered with vaccine programs included empioyees who were unaware of risk and the vaccine offer (25%), lack of available funds (21%), lack of hospital administrations’ support and interest in program (15%)‘ facility’s need for a case of hepatitis B to institute program (8%), disagreement concerning identity of at-risk employees (6%), lack of ICP’s time for program (6%), fear of AIDS (5%), administration of gluteal rather than deltoid injections (5%). Finally, the ICPs’ professional recommendations for future programs were giving free vaccine to high-risk employees (20%)‘ making educational programs mandatory (20%), effecting careful planning and follow-up actions (140/o), involving key personnel (12%), demonstrating cost effectiveness to hospital administrators (7%), consulting legal consul for consent forms (5%), making use of good public relations to encourage participation (5%), screening of blood after vaccination to determine antibody status (4%), consultating with representatives of Merck Sharp & Dohme for helpful information (4%), and administering injections into deltoid, not gluteal, muscle (2%). DlSCUSSMXd
This survey collected subjective opinions hepatitis B immunization programs from
on at-
Volume June
17 Number
3
1989
tendees at an APIC conference. It should be noted that the sample surveyed may not be representative of ICPs nationwide, and the survey results may not be an objective measure of success of hepatitis B immunization programs across the country. We were pleased, however, with the high rate and quality of response to the survey. We believe that the process of conducting a survey at a convention should be given consideration by other researchers. We also were pleased to note that many ICPs reported their involvement in similar programs. Their comments indicated a high level of consistency and professionalism evident from the design, operation, and success of the programs. Overall, it appears that hepatitis B vaccine programs are widespread and generally have been satisfying to ICPs representing facilities across the country that were surveyed at the APIC conference. Some of the features they liked best about their programs were the protection of their employees against hepatitis B and vaccination being offered free of charge. They believed they were providing an educational opportunity for their employees to become more aware of the risks involved and helping them reach a decision about their involvement in the program. Further, ICPs believed their programs were instrumental in bringing about changes in the puncture wound policies to prevent the spread of hepatitis B. Finally, they indicated that the programs brought together the ICP, administration, and physicians for mutual support in a common cause. At the time of this survey 32% of inservice programs were mandatory. Many ICPs believed that more such programs should be sponsored by the health care facility and that attendance should be mandatory for high-risk employees. The Occupational Safety and Health Administration (OSHA) guidelines,3 which concern mandatory hepatitis B vaccine for high-risk employees who perform category I tasks that involve exposure to blood, body fluids, or tissues, validate these opinions. CONCLUSIONS
The implementation of the hepatitis B vaccine programs has provided a golden opportu-
National
survey of hepatitis
B vaccine
programs
IS3
nity for ICPs to demonstrate their capabilities and value. By assuming administrative management responsibilities for their programs, ICPs indicated they were able to translate their administrations’ interest and concern for employees into a protective and cost-effective “we care” programs. By acting as careful monitors and effective managers of the ongoing vaccination programs, ICPs were established as key members of the facilities’ management teams. The ICPs surveyed stated that hepatitis B vaccine programs have led to an expanded role definition by employees. Because of the ICPs’ professional knowledge and guidance and their direct involvement in the educational efforts, ICPs began to be seen as active counselors and sources of support for employees. The importance of the hepatitis B programs and their wide impact in institutions also contributed to the perceptions of ICPs as advocates for employees’ health and welfare. The increased professional recognition and the personal job satisfaction that developed out of involvement in the hepatitis B vaccination programs provided a shot in the arm for ICPs. Mandatory OSHA guidelines may reduce the expressed reasons for unsuccessful vaccination programs such as the lack of available funds to carry out the program, lack of administrative support, and lack of employee awareness of the programs. We acknowledge the support of the National Association for Practitioners in Infection Control (APIC), the Board of Directors and members of APIC-Southeastern Wisconsin for their support in the initial phase of this project; we thank James R. Coakley, DDS, for the manual tabulation of the surveys; Glenn L. Loschenkohl for the statistical analysis of the data; and all the infection control practitioners who completed this survey.
References 1. Norusis J. Statistical package for the social sciences. Chicago: SPSS, Inc., 1987. 2. Harman HH. Modern factor analysis. Chicago: University of Chicago Press, 1987. 3. Joint Advisory Notice, Department of LaborlDepartment of Health and Human Services. HBVIHIV. Federal Register. 1987 Ott 30;52:41818-24.
In May 1982, at the Eighth Annual Educational Conference of the Association for Practitioners in Infection Control (APIC), the upcoming release of Heptavax-B (Merck Sharp & Dohme) was announced. Since then, on the basis of the number of doses of hepatitis B vaccine distributed, approximately 2.5 million persons have received hepatitis B vaccine in this country (Merck Sharp & Dohme market research data on file, February 1989). This article reports the results of a national survey of APIC practitioners on the administration of hepatitis B programs. METHODS
A survey, which was developed to determine the progress of hepatitis B vaccination programs after the 1982 release of Heptavax-B, was distributed at the Thirteenth Annual Educational Convention of the Association for Practitioners in Infection Control in May 1986 in Las Vegas, Nevada (Fig. 1). The study was conceived, designed, and administered by an APIC member who gave a small box of stationery to each participant in appreciation for participation in this effort. From Froedtert Memorial Lutheran Hospital, Milwaukee, University of Wisconsin-Parkside, Kenosha, and Humber, Mundie and McClary, Milwaukee. Financial support for survey printing provided by Merck Sharp & Dohme. Reprint requests: Linda J. Hanacik, RN, CIC, Nurse Epidemiologist, Froedtert Memorial Lutheran Hospital, 9200 West Wisconsin Ave., Milwaukee, WI 53226. 148
The survey contained nine questions that solicited 59 different responses from participants. Items were either multiple choice or short answer to be completed on the basis of the participants’ knowledge of their facility’s program at the time of the conference. Descriptive statistics were calculated with the use of the Statistical Package for the Social Sciences (SPSS).’ Further analyses included selected cross-tabulations and correlations. Because the investigators had no definite hypotheses about the number or the composition of factors, we chose to do a principal component factor analysis’ to determine the smallest number of factors needed to explain all the common variance in all of the questions. We used the Varimax selection criteria, that is, retaining factors with eigenvalue of 1 .O or greater, which~ ensured that we retained only factors that explained more variance than was explained simply by the component questions. Our factor analysis was enhanced by the use of a Varimax rotation,2 a process that leads to a clearer separation of factors by limiting the number of questions that have high correlations on a given factor. Questions that involved short essay responses were manually categorized and tabulated.
Of the 800 surveys distributed, 449 (56%) were returned (439 at the convention and 10 mailed in later). Demaphic data revealed that respondents were from 45 -states and the District of Columbia; states not included were
Volume 17 Number 3 June 1989
National survey of hepatitis B vaccine programs
Fig. 1. Hepatitis B program survey Directions: Please place an “x” in the box(es) that most closely 1. Do you work in a: 0 Hospital 0 Nursing home/extended 2. What is the estimated average patient census in your institution?
q Cl00
q
100-200
q
q
200-400
149
indicates your response. care facility?
>400
In which state is your institution located? 4. What is the population of the community in which your institution is located? 0 <10,000 q 10,000-39,000 0 40,000-100,000 q >100,000 5. The following is a list of populations at increased risk for hepatitis B. Please indicate which population(s) would routinely be cared for at your institution. 0 Homosexually active males 0 Male prisoners 0 Immigrants/refugees 0 Institutionalized mentally Cl Contacts of hepatitis B carriers 0 Staff of institution of 0 Hemodialysis patients mentally handicapped handicapped 0 IV drug users 0 Health care workers with frequent blood contact 6. Has your institution offered the hepatitis B vaccine to its employees? q Yes q No If yes, complete the remaining questions in No. 6. If no, skip to question No. 7. a. What year was the first dose of hepatitis B vaccine given?
3.
0 ‘82
q
‘83
0 ‘84
q
‘85
q
‘86
b. Personnel in are included Yes No N/A 0 0 0 0 0 0
c. d. e. f. g.
h. i, j.
k. I.
the following departments are considered at increased risk for hepatitis B. Please indicate which departments in your vaccination program. Yes No N/A Emergency room 0 0 q IV team Operating room 0 0 0 Clinic areas 0 q q Recovery room 0 0 0 Phlebotomists 0 0 0 Respiratory therapy 0 0 0 Labor and delivery Cl 0 0 Intensive care Other Cl •1 0 Dialysis 0 0 0 Code 4 team Estimate the percentage of employees at increased risk over total employees population. % Did your vaccination program offer special inservice presentations? 0 Yes q No If yes, were these mandatory? q Yes q No Did employees who received vaccine sign a consent form? q Yes 0 No 0 Unsure Did employees who refused the vaccine offer sign a refusal form? 0 No q Yes Cl Unsure In the list below are 9 common reasons why people do not accept vaccine. Please rate in order (1 = most common reason) for refusing. If female, concerns of pregnancy, or lactation? Newness of vaccine? (released in 1982) Concern of side effects? Personal convictions? Concern of AIDS? __ Didn’t feel you had enough exposure to hepatitis B to get vaccine? ___ Lack of knowledge concerning vaccine benefitslsafetyleff icacy? Cost to employee? Other? Who paid for vaccination program for increased risk employees? 0 100% institution Cl 100% employee q Co-pay Give your estimate of percentage of employees offered vaccine who received first dose. % Percent receiving third dose. % Rank in order (1 = most) department contributing the most amount of time on vaccine program. Infection control Personnel department Other ~ Employee health Hospital administration Did you have any personal responsibility for the program? 0 Yes q No In retrospect, to what degree were you satisfied with the vaccination program? 1 2 4 3 5 Very dissatisfied Very satisfied
Continued.
Amencan
1 SO Hanacik et al. Continued. m. In the next 3 years, 0 Expanding n. Have your employee 0 Yes If yes, how: o.
Do you
p.
What
Journal
INFECT!ON
do you see your vaccination program 0 Maintaining 0 Reducing i: Canceling health policies changed in regard to hepatitis B exposure 0 No
prophylaxis
as a result
of your
program?
_-___l_l._
feel that hepatitis B vaccination 0 Yes 0 No were the three aspects you liked
programs best
about
are cost
effective
in the long
run?
the program?
--
1)
Thank
you
for completing
this
survey.
If your
facility
did not have
a program,
respond
below.
7. If you did not have a vaccination program, was it due to any of the following? Please indicate responses in order of reason (1 = most common) Yes No Ranking order Lack of funds cl0 Lack of cooperation between departments q n Program too time-consuming no on Low hepatitis risks in your institution Fear of AIDS UC] Unknown short-term side effects on Unknown long-term side effects No employee health program E Waiting for synthetic vaccine on Other on 8. In the space below, describe the status with any difficulties or complicating factors which have
9. Whether or not your institution has considering a vaccination program?
Thank
01
CONX-301.
you
for completing
a hepatitis
B vaccination
program,
what
would
be your
either
influenced
professional
yes
or no and
your
advice
rank yes
program.
for sameone
this survey.
Arkansas, Delaware, Idaho, Mississippi, and South Dakota. The majority (95%) of infection control practitioners (ICPs) worked in hospitals; 3% worked in extended care facilities. More than 90% of respondents had active hepatitis B vaccination programs. On the basis of
average daily census a wide range of institutional sizes was reported: 17%, fewer than 100; 24%, 100-199; 32%, 200-399; and 27%, 400 or more patients per day. More than half (54%) of the facilities served communities with populations larger than 100,000, 26% were ins the
Volume
17 Number
3
June 1989
range of 40,000-99,999, 16% were in the range of lO,OOO-39,999, and only 4% represented communities with a population less than 10,000. The vast majority of ICPs (90%) estimated that fewer than half of the employees at their institutions were at increased risk for hepatitis B. Table 1 lists populations at increased risk that are routinely cared for by the respondents’ health care facilities. The survey data indicated that 90% of the ICPs who responded offered hepatitis B vaccine to their employees, with the majority of the first doses being offered in 1983 (29%) and 1984 (24%). Of the vaccine programs 83% offered special inservice presentations. Of these 32% were mandatory. A principal components factor analysis was done on the survey results. This kind of analysis examines the variance in the responses to the survey. Groups of items that share variance were identified as factors. This survey yielded eleven interpretable factors with eigenvalues greater than 1 .O. Some common elements were observed in these factors, which is not unusual for these kinds of analyses. To facilitate interpretations we grouped factors into four main categories. Category one (reasons for refusing hepatitis B vaccine) was composed solely of factor one and explained 10.9% of the variance. Items included in the questionnaire that contributed to this category were alternatives dealing with vaccine refusal (question No. 6g) (e.g., lack of vaccine knowledge concerning benefits, safety and efficacy, lack of sufficient blood exposure to warrant vaccine, newness of vaccine, concern for side effects, concern about acquired immunodeficiency syndrome [AIDS], pregnancy and lactation among women, personal convictions, costs to employees, and other concerns) and the involvement of hospital administrators and personnel departments as the major developers for hepatitis B vaccination programs in their health care facility (question No. 6j). The second category (high-risk departments to which vaccine was offered) (question No. 6b) summarized the data of departments within facilities and their level of participation within the programs. This grouped three of
National
survey of hepatitis
B vaccine
programs
151
Table 1. Number of persons surveyed who indicated that care was routinely given at their facility to specific high-risk populations Populatkm
at high
risk
Health care workers Intravenous drug users Patients receiving hemodialysis Contacts of hepatitis B carriers Homosexually active men Immigrants and refugees Institutionalized mentally handicapped persons Male prisoners Staff at institutions for the mentally handicapped
No.
(%I
364 287 265 260 247 175 121
(81)
99 76
(22)
w (59) (58) (55) (39) (27) (17)
the factors and explained 17% of the variance in survey responses. In health care institutions, on the basis of frequency of blood contact, personnel in certain departments were at increased risk for hepatitis B. In those facilities that included such departments, the percentage of respondents indicating inclusion of the department in the vaccine program were dialysis (99%), emergency room (980/o), operating room (98%), phlebotomy (98%), intensive care unit (96%), intravenous team (95%), recovery room (92%), labor and delivery (90%), code 4 team (83%), respiratory therapy (78%), and clinic areas (62%). The third category (successful programs) grouped items describing reasons for successful hepatitis B vaccination programs. It included four other factors and explained 18.8% of the variance. Items included in this category were use of signed consent/refusal form (question Nos. 6e and 6f), level of ICPs’ satisfaction (question No. 61), degree of compliance with first or third dose of vaccine (question No. 6i), whether ICPs contributed a high percentage of time if inservice programs were offered (question No. 6d) and if so, whether they were mandatory, and whether ICPs conducted the training programs (question No. 6k). The last category (expansion of program) grouped the remaining three factors and described the reasons for program expansion. This category accounted for 8.9% of the variance. Items included cost effectiveness of the pro-
0mer:can
IS2
Hanacik et al.
gram (question No. 60)~ plan for expansion during the subsequent 3 years (question No. 6m), employee health policy changes (question No. 6n), involvement of employee health department (question No. 6j), other departments’ contribution of time to the program (question No. 6j), high number of employees at risk for hepatitis B (question No. 6c), vaccine provided for code 4 team (question No. 6b), and employees’ belief that their length of exposure did not warrant vaccine (question No. 6g). In summary, four factors explained most of the variance in the answers to the survey questions: (1) the reasons for refusing hepatitis B vaccine, (2) high-risk departments to which vaccine was offered, (3) grouping items dealing with successful programs, and (4) the expansion of programs. Respondents ranked the departments according to their contribution of time on the vaccine program; 8 1% reported involvement by the ICP. The percentage of respondents who reported involvement of other departments were employee health service (71%), hospital administration (6%), personnel department (5%), and other departments (3.5%). A Likert scale was used to rate level of satisfaction with the vaccine programs: 17%, very satisfied; 24%‘ moderately satisfied; 30%, neither satisfied or dissatisfied; 13%, mildly dissatisfied; and 5%, very dissatisfied. Perhaps in part because of the high level of satisfaction with the hepatitis B vaccination programs, 36% of the survey respondents indicated that they planned to expand the program, 49% planned to maintain it, but a few planned to reduce (4%) or cancel (1%) it. Vaccine programs were also believed to be cost effective by 79% of all respondents. The next section of the survey solicited openended comments from ICPs about employee health policy changes, aspects of programs ICPs liked best, complicating factors, and the 1CP.s’ professional advice for future programs. Although not many comments were made about changes in employee health policies, decreases in antibody testing and prophylaxis medication administration were reported by 29 (11%) respondents, and a decrease in the use of hepatitis B immunoglobulin was seen in 27 (10%). Other responses tallied included recommendations to
INFECVOK
Journal
of
CONTROL
establish a protocol to check for protective antibodies after puncture wounds, 28 (lO%j; improved reporting and follow-up of’ puncture wounds, 12 (4%); and reduction of screening after vaccination, 13 (5%). The aspects the ICPs liked best about their programs were that they provided an educational opportunity for employees to learn about hepatitis (26%), the protection and safety the vaccine provides (22%), facility-sponsored program to employees at increased risk for hepatitis B (18%), the need to change and update their puncture wound protocols (1 I%), and the cooperation of the hospital administrators, physicians, and department managers (7%). Other less frequently described comments included the cost effectiveness of the program (4%), the opportunity to demonstrate a “we care” attitude toward employees (3%), and the ease of vaccine program implementation (2%). Complicating factors that interfered with vaccine programs included empioyees who were unaware of risk and the vaccine offer (25%), lack of available funds (21%), lack of hospital administrations’ support and interest in program (15%)‘ facility’s need for a case of hepatitis B to institute program (8%), disagreement concerning identity of at-risk employees (6%), lack of ICP’s time for program (6%), fear of AIDS (5%), administration of gluteal rather than deltoid injections (5%). Finally, the ICPs’ professional recommendations for future programs were giving free vaccine to high-risk employees (20%)‘ making educational programs mandatory (20%), effecting careful planning and follow-up actions (140/o), involving key personnel (12%), demonstrating cost effectiveness to hospital administrators (7%), consulting legal consul for consent forms (5%), making use of good public relations to encourage participation (5%), screening of blood after vaccination to determine antibody status (4%), consultating with representatives of Merck Sharp & Dohme for helpful information (4%), and administering injections into deltoid, not gluteal, muscle (2%). DlSCUSSMXd
This survey collected subjective opinions hepatitis B immunization programs from
on at-
Volume June
17 Number
3
1989
tendees at an APIC conference. It should be noted that the sample surveyed may not be representative of ICPs nationwide, and the survey results may not be an objective measure of success of hepatitis B immunization programs across the country. We were pleased, however, with the high rate and quality of response to the survey. We believe that the process of conducting a survey at a convention should be given consideration by other researchers. We also were pleased to note that many ICPs reported their involvement in similar programs. Their comments indicated a high level of consistency and professionalism evident from the design, operation, and success of the programs. Overall, it appears that hepatitis B vaccine programs are widespread and generally have been satisfying to ICPs representing facilities across the country that were surveyed at the APIC conference. Some of the features they liked best about their programs were the protection of their employees against hepatitis B and vaccination being offered free of charge. They believed they were providing an educational opportunity for their employees to become more aware of the risks involved and helping them reach a decision about their involvement in the program. Further, ICPs believed their programs were instrumental in bringing about changes in the puncture wound policies to prevent the spread of hepatitis B. Finally, they indicated that the programs brought together the ICP, administration, and physicians for mutual support in a common cause. At the time of this survey 32% of inservice programs were mandatory. Many ICPs believed that more such programs should be sponsored by the health care facility and that attendance should be mandatory for high-risk employees. The Occupational Safety and Health Administration (OSHA) guidelines,3 which concern mandatory hepatitis B vaccine for high-risk employees who perform category I tasks that involve exposure to blood, body fluids, or tissues, validate these opinions. CONCLUSIONS
The implementation of the hepatitis B vaccine programs has provided a golden opportu-
National
survey of hepatitis
B vaccine
programs
IS3
nity for ICPs to demonstrate their capabilities and value. By assuming administrative management responsibilities for their programs, ICPs indicated they were able to translate their administrations’ interest and concern for employees into a protective and cost-effective “we care” programs. By acting as careful monitors and effective managers of the ongoing vaccination programs, ICPs were established as key members of the facilities’ management teams. The ICPs surveyed stated that hepatitis B vaccine programs have led to an expanded role definition by employees. Because of the ICPs’ professional knowledge and guidance and their direct involvement in the educational efforts, ICPs began to be seen as active counselors and sources of support for employees. The importance of the hepatitis B programs and their wide impact in institutions also contributed to the perceptions of ICPs as advocates for employees’ health and welfare. The increased professional recognition and the personal job satisfaction that developed out of involvement in the hepatitis B vaccination programs provided a shot in the arm for ICPs. Mandatory OSHA guidelines may reduce the expressed reasons for unsuccessful vaccination programs such as the lack of available funds to carry out the program, lack of administrative support, and lack of employee awareness of the programs. We acknowledge the support of the National Association for Practitioners in Infection Control (APIC), the Board of Directors and members of APIC-Southeastern Wisconsin for their support in the initial phase of this project; we thank James R. Coakley, DDS, for the manual tabulation of the surveys; Glenn L. Loschenkohl for the statistical analysis of the data; and all the infection control practitioners who completed this survey.
References 1. Norusis J. Statistical package for the social sciences. Chicago: SPSS, Inc., 1987. 2. Harman HH. Modern factor analysis. Chicago: University of Chicago Press, 1987. 3. Joint Advisory Notice, Department of LaborlDepartment of Health and Human Services. HBVIHIV. Federal Register. 1987 Ott 30;52:41818-24.