Increasing Immunization Rates Through Worksite Vaccination Clinics - Q&A With Bruce Sherman, MD, FCCP, FACOEM

December 24, 2019

AJMC

AJMC®: What role does and should preventive care play in the broader healthcare spectrum?

Sherman: In terms of the role that preventive care should have, ideally, every individual would be attentive to recognizing evidence-based recommended preventive care services that are available to them—based on their age, gender, race—and is compliant with such. This would allow them to maintain their health and well-being, identify problems early if they exist, and, in the case of immunization, potentially avoid problems with proactive measures.

However, there are limitations regarding the extent to which people engage and are compliant at the receipt of recommended preventive care services. There may be many factors that get in the way of compliance. For instance, we know that socioeconomic status is a significant issue. Regarding employees, we also appreciate that employers may have work schedules that limit employee access to receiving certain preventive care measures, such as those requiring them to have to leave work to receive care in a doctor’s office; hourly workers may be penalized for leaving work. Also, preventive care may not be a high priority for someone who otherwise is feeling fine and doesn’t perceive the value of preventive care in the same way that their medical professional might.

AJMC®: What are the challenges of conveying the importance and benefits of long-term preventive care?

Sherman: For many individuals, it’s an issue of behavioral economics. If we think about the negative factors—whether that’s the time to get vaccine, or the pain and subsequent symptoms associated with it—those are all immediate considerations. The potential for avoidance of a future vaccine-preventable illness is vague and intangible for most people. Trying to help people weigh that decision balance and to help them understand that some discomfort now is worth illness avoidance later, can be a bit of a challenge. One of the opportunities to influence this balance is to lower the barrier to vaccinations by making them more convenient and accessible, for example, with onsite immunization programs. Another issue is there is a tremendous amount of misinformation in the marketplace in relation to immunization; for example, there are many people who think they can get the flu from the influenza vaccine; there are also “anti-vaxxers”. Our challenge is to effectively demonstrate the inaccuracies in their arguments.

AJMC®: What do you think is needed to foster that greater awareness regarding immunization?

Sherman: A well organized, thoughtful educational campaign is certainly helpful from a population-level perspective. That being said, I’m not sure that, based on our research, even with more education that we’re going to change minds. Where we probably have more opportunity is with case studies, in other words not to use science, per se, to create argument/rationale but actually use emotion. If people didn’t get a vaccine and had an untoward outcome, that’s a very powerful story. A combination of education and case scenarios represent of a broader, strategic approach.

AJMC®: You coauthored a study on flu vaccination in the workplace.1 What was the rationale for the study and what were some of the key takeaways from the findings?

Sherman: Before beginning work on this study, I had been working as a medical director with a national worksite clinic vendor. I had a good bit of experience with worksite flu vaccine programs, recognizing that we were doing a pretty good job of capturing the employee population but not spouses and children. We recognized that children were potentially the biggest vector of flu transmission through their encounters with their classmates. It seemed important to immunize not only the employees but their spouses and children as well.

At that point in time, we weren’t aware of any employers that provided worksite flu vaccination to more than just the employees. Also, as part of our discovery process, we talked to employers and looked at the proportion of employers that offer onsite vaccination, and were struck by the fact that more focus was directed to companies that offered programs-- and much less to the actual participation rates as a more valid measure of program success. We thought there was a clear opportunity to find a better way to be more effective with immunizing individuals.

We wanted to not only gain a better understanding of individuals’ knowledge of flu vaccines but also assess the impact of a communications campaign targeted at misconceptions people had about the flu. We also wanted to explore the different options for immunizing employees and family members, with the thought that maybe we could capture more people using a broader approach. We were also curious to see where people were being immunized, whether at the workplace, the doctor’s office, the retail drug store/clinic, or other settings.

What our study showed was that there were significant misconceptions about both the pros and cons of flu vaccines. Importantly, implementation of a targeted education program didn’t really change the way people felt about the vaccine. They had preconceived notions that weren’t influenced by the communications we provided to them. What we did find most impactful was that an immunization program at a company event that allowed for immunization not only of employees but also spouses and children was most successful at generating the greatest percentage of immunization rates of eligible individuals, a rate that far exceeded what was happening in the community.

Our takeaway was that education campaigns alone may not represent the best approach for improving vaccination rates. Making a vaccine available and appealing to individuals on perhaps more of spontaneous basis perhaps could be helpful in increasing rates. The other intriguing point we found was that when we queried our data we found a general concordance that if employee wasn’t vaccinated, the spouses and children were also likely not vaccinated.

[Given these findings,] there is an opportunity for employers to foster a more thoughtful approach regarding immunization services. Perhaps employer-sponsored immunization events may be most successful when included as part of broader activity that engages family members.

AJMC®: How receptive are employers to these concepts and what tips can you share for “selling” employers on offering preventive care services?

Sherman: The truth is that there are very few healthcare services that, when provided, are actually cost-saving. There is likely more of a value here in promoting immunizations to demonstrate that employers care about employee and family well-being.

That said, there are some data to suggest that, in the event of a severe influenza outbreak, there well may be business value created for employers that have an effective immunization campaign because that may reduce the potential for flu-associated lost work time, impaired productivity, or worker absence. However, an epidemic of that magnitude is likely very infrequent if not rare. For other, non-influenza immunizations, there is not an economic benefit, per se, from a healthcare cost standpoint. But there is a philosophical or strategic benefit to promoting employee well-being — and it’s the right thing to do from an employer’s perspective to promote community health.

AJMC®: How valuable is similar research regarding the potential benefits of other vaccines in workplace settings?

Sherman: There is value, but the challenge is the record keeping and documentation of immunization, especially for immunizations that require only one or two injections in a lifetime. The employer may only have medical claims data that go back 3 years, for example, or employee job changes may limit the ability for employers to document whether vaccinations have been provided. Many employers use health risk assessments that allow for collection of patient self-reported data about immunization status. Such data would permit directed outreach to those individuals who have not received appropriate vaccines.

AJMC®: What are the managed care implications regarding the need for wider adoption of immunization services?

Sherman: The issue is really a public health concern. From that perspective, I think with the US Preventive Services Task Force recommendations and Affordable Care Act first-dollar immunization coverage, there is a general acceptance and recognition of the value of immunizations. While a health plan or employer may recognize that they may not derive immediate financial benefit from immunization of a plan enrollee, they may actually derive benefit from someone who was immunized while enrolled in another health plan. Because the net benefit is for the common good, ultimately, every health plan or employer should do their best to comply with evidence-based care and ensure that individuals are vaccinated in accordance with recommended guidelines.

AJMC®: Given the need for increased adoption of immunization, can you suggest any core take-home points regarding strategies to improve vaccination rates?

Sherman: To me, the biggest consideration is that it’s not enough for employers to simply make immunization programs available to employees. Employers should also look at their actual participation rates in those programs. Based on an understanding of their own data, employers can then refine their efforts to encourage more individuals to be immunized. This process may well increase healthcare costs, but if done in a thoughtful way, individuals will feel that their employer is being supportive of their health. That message will be received favorably even if employees opt out of receiving those immunizations.1. Ofstead CL, Sherman BW, Etzler HP, et al. Effectiveness of worksite interventions to increase influenza vaccination rates among employees and families. J Occup Environ Med. 2012;00(00):1-8. doi: 10.1097/JOM.0b013e3182717d13.