BACKGROUND/RATIONALE:
Persons with SCI/D are at high risk of respiratory complications from influenza. Intervention through infection control (IC), vaccination, and antiviral medications can reduce risk. Attention is needed during uncertain emergent situations such as the 2009 H1N1 influenza pandemic to understand how the intended communication and IC processes were carried out, especially in high risk groups such as SCI/D.

OBJECTIVE(S):
Aim-1. To assess SCI/D health care workers' (HCWs) use of/beliefs about IC strategies and perceptions of evidence strength and facility enforcement of IC measures.

Aim-2. To understand resource availability, hospital preparedness, communication, and information sources, in VA, and the SCI/D System of Care.

Aim-3. In Veterans with SCI/D, to assess influenza (H1N1 and seasonal) vaccination; information sources, knowledge, amount, and clarity of H1N1 information; and variables associated with H1N1 vaccine receipt.

Aim-4. To assess use of antiviral medications for influenza in Veterans with SCI/D.

METHODS:
Aim-1. Cross-sectional anonymous mailed survey of SCI/D HCWs (physician, physician assistant, nurse practitioner, nurse, nursing aide, nurse assistant). Key outcomes: IC practices and beliefs, perceptions of evidence strength and facility enforcement of H1N1 prevention measures. Analyses included descriptive and bivariate statistics. Sample: 460 HCWs (17 Hubs, 15 Spokes), 47% response.

Aim-2. Semi-structured interviews. Main outcomes: IC office structure, resource availability, hospital preparedness, and communication/information-sharing. Content analysis, coding, and data reduction used to identify themes. Sample: 33 IC key informants (18 Hubs, 15 Spokes).

Aim-3. Cross-sectional mailed survey of Veterans with traumatic and non-traumatic SCI/D. Main measures: influenza (H1N1 and seasonal) vaccination; information sources used; ability to address influenza concerns; knowledge, amount, and clarity of H1N1 information. Bivariate and multivariate analyses were used to identify associations of variables and H1N1 vaccine receipt. Sample: 3544 Veterans with SCI/D (39% response) from 18 nationwide Hubs.

Aim-4. Retrospective chart reviews of visits/admissions associated with an influenza diagnosis and/or antiviral prescription between 10/01/07-5/31/10. Key measures included influenza diagnosis and appropriate antiviral prescribing. Data sources: charts, VA IP/OP SAS data sets and VA DSS. Data analyses included descriptive and bivariate statistics. Sample: 101 Veterans with SCI/D.

FINDINGS/RESULTS:
Aim-1. 48% of SCI/D HCWs received H1N1 influenza vaccine, 57% placed Veterans with SCI/D with suspected/confirmed influenza into isolation "all of the time, " and 17% were less likely to recommend influenza vaccine during the pandemic season. HCWs who rated clinical expert opinion as supportive of H1N1 IC practices were more likely to adopt H1N1 IC practices and to perceive facility enforcement of H1N1 IC as high (p<0.05), but HCW's perceptions of research evidence and patient preferences were not associated with either.

Aim-2. 76% of facilities had a dedicated IC officer/chief, but only 45% had dedicated respiratory or influenza IC staff. Few (15%) used simulations/drills for preparedness. 73% thought employee IC adherence was higher during the pandemic. Due to inadequate supply, facilities rationed H1N1 vaccine to HCWs (42%), high-risk Veterans (33%), or small groups of both (24%). 79% thought Veterans with SCI/D were at increased risk for influenza and complications, but, only 52% of facilities treated SCI/D as a priority group for H1N1 vaccination. VA national leadership (76%) and CDC (73%) were common H1N1 information sources. Barriers included conflicting information, changing information without timely dissemination, lack of definitive "VA stance", and staff shortage.

Aim-3. 58% of Veterans with SCI/D received the H1N1 vaccine (83% received seasonal). Less than 2/3 of the non-H1N1 vaccine group planned to get next season's vaccine. H1N1 influenza information sources were VA health professionals (55%), television (53%), printed materials (30%), family/friends (19%), and 5% turned to social media. H1N1 vaccine receipt was higher when the information source was VA health professionals (66%) vs. all other sources (49%), p<0.0001. Veterans with SCI/D (88%) were very/mostly satisfied with their ability to address influenza-related concerns at their VA facility. Being 50 years or older [OR=1.33, 95% CI 1.07 - 1.70), depressed [OR=1.29, 95% CI 1.07 - 1.55], and in fair/poor health (vs. good) [OR=1.16, 95% CI 0.95 - 1.41] were associated with higher odds of H1N1 vaccination. Recipients of an 'adequate amount' (1.8x) and 'accurate/clear' (2x) information were more likely to receive H1N1 vaccine, p<0.0001.

Aim-4. 23% of SCI visits/admissions resulted in appropriate antiviral prescribing. In SCI/D, appropriate antiviral prescribing increased from 16% in FY08 to 29% in FY10. Of those with an influenza ICD-9 code, 63% had influenza symptoms, positive culture results, or physician documentation of influenza in the medical record. Of those with influenza, 45% were prescribed antivirals appropriately. Appropriate antiviral prescribing rate was 41% post-H1N1 pandemic vs. 22% prior to and during the pandemic.

IMPACT:
Collectively, these findings can be used to facilitate preparedness for future pandemics and other emergent situations in VA facilities.

1/3 of facilities rationed H1N1 vaccine to high-risk Veterans, but only 52% of the facilities treated SCI/D as a priority group. H1N1 vaccine receipt was very low (48%) for SCI/D HCWs and 17% were less likely to recommend influenza vaccination during the pandemic season. Clinical expert opinion was significantly associated with HCW adherence to IC practices. Future strategies should include a clear communication plan (multiple channels, timely, organized), preparedness tests/simulations, advanced preparation for additional staffing needs, use of expert opinion to enhance HCWs' IC guideline adherence, and extra guidance for IC staff on influenza risk and vaccine priorities for Veterans with SCI/D during pandemic situations.

H1N1 influenza vaccination rate was low (58%) in veterans with SCI/D and many non-recipients (63%) did not plan to get an influenza vaccination the next season. 'Not enough' and 'confusing/conflicting' information were each associated with lower odds of receiving H1N1 vaccine. To alleviate concerns and skepticism generated by the 2009 H1N1 influenza pandemic, efforts are needed to share information with this high-risk cohort, so that carry over effects from the pandemic do not avert future healthy IC behaviors.

SCI/D was not classified as a H1N1 vaccine priority group; so antiviral medication and isolation strategies could have provided extra protection. However, given that only 23% of SCI visits/admissions were prescribed antivirals appropriately and only slightly over half of HCWs consistently placed Veterans with SCI/D with suspected/confirmed influenza into isolation, improvement efforts are needed.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Ullrich PM, Lavela SL, Evans CT, Miskevics S, Weaver FM, Goldstein B. Associations between perceptions of evidence and adoption of H1N1 influenza infection prevention strategies among healthcare workers providing care to persons with spinal cord injury. Journal of Advanced Nursing. 2014 Aug 1; 70(8):1793-800. [view]
2. Locatelli SM, LaVela SL, Hogan TP, Kerr AN, Weaver FM. Communication and information sharing at VA facilities during the 2009 novel H1N1 influenza pandemic. American journal of infection control. 2012 Sep 1; 40(7):622-6. [view]
3. Lavela SL, Goldstein B, Etingen B, Miskevics S, Weaver FM. Factors Associated With H1N1 Influenza Vaccine Receipt in a High-Risk Population During the 2009-2010 H1N1 Influenza Pandemic. Topics in spinal cord injury rehabilitation. 2012 Jan 1; 18(4):306-14. [view]
4. Etingen B, LaVela SL, Miskevics S, Goldstein B. Health information during the H1N1 influenza pandemic: did the amount received influence infection prevention behaviors? Journal of community health. 2013 Jun 1; 38(3):443-50. [view]
5. Evans CT, Rogers TJ, Goldstein B, Weaver FM, LaVela SL. Influenza antiviral treatment in spinal cord injury patients, 2007-2010. The journal of spinal cord medicine. 2015 Jan 1; 38(1):48-56. [view]
6. Locatelli SM, Lavela SL, Hogan TP, Goldstein B. Influenza infection control guidance provided to staff at Veterans Affairs facilities for veterans with spinal cord injury during a pandemic( ). The journal of spinal cord medicine. 2013 Nov 1; 36(6):666-71. [view]

Conference Presentations

1. Locatelli (House) SM, LaVela SL, Hogan TP, Kerr A, Tully S, Weaver FM, Goldstein B. Information sharing at VA facilities during the 2009 Novel H1N1 pandemic. Paper presented at: International Conference on Communication in Healthcare; 2011 Oct 17; Chicago, IL. [view]
2. LaVela SL, Etingen B, Goldstein B. The Influence of Health Information on Response to an Influenza Pandemic Crisis. Poster session presented at: Association for Psychological Science Annual Convention; 2012 May 24; Chicago, IL. [view]

DRA: Health Systems Science, Brain and Spinal Cord Injuries and Disorders, Infectious Diseases
DRE: Prevention
Keywords: Infectious disease, Prevention, Spinal cord injury
MeSH Terms: none