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Dialysis Patient Influenza Vaccination Protocol

Dialysis Patient Influenza Vaccination Protocol
Background
Influenza infections are associated with increased medical costs, hospitalizations, lost
productivity, and thousands of deaths every year in the United States. The majority of deaths
from seasonal influenza occur in adults aged ≥65 years.1-4 Annual influenza vaccination is the
best way to reduce the risk for complications from influenza infections and in the United States
is now recommended for all persons aged ≥6 months.
Annual epidemics of seasonal influenza usually occur during the late fall through early spring
each year. During these times, rates of infection with influenza are highest among persons aged
≥65 years of age, in children <2 years and persons of any age who have medical conditions
placing them at increased risk for the complications of influenza.5-7 Occasionally, a variant strain
of influenza will emerge that is distinct from the expected seasonal strain and requires a separate
vaccination for prevention. For example in 2009/2010, the non-seasonal strain was novel
Influenza A (H1N1) 2009. Annual influenza vaccination is the most effective way to prevent
influenza virus infection and its complications.
Methodology
The Dialysis Patient Influenza Vaccination Module targets the dialysis facility’s population,
greater than 6 months of age. Monthly data collection (prospective surveillance) is used. When
vaccinations for more than one subtype are recommended during a season, report denominator
data separately for each vaccination subtype (i.e., seasonal and non-seasonal).
An individual, trained on this Protocol, shall initially seek to identify any and all maintenance
dialysis patients treated at the facility as meeting criteria for seasonal vaccination during the
review period, and determine if influenza vaccination was offered, and then either accepted or
declined.
The CDC forms 57.505, 57.506 are used to collect all required data for this module. The
minimum requirement to participate in this module is one month during the influenza season
(September through April), but maximal benefit is obtained by completing the module for each
month of the entire influenza season.

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Dialysis Patient Influenza Vaccination Protocol

Monthly Data Collection (Prospective Surveillance)
Introduction: Prospective surveillance requires the use of two forms, the Dialysis Patient
Influenza Vaccination Denominator form (CDC 57.506), and the Dialysis Patient Influenza
Vaccination form (CDC 57.505) to collect all data for the period of surveillance. The patient
vaccination forms must be completed when the facility is performing an influenza vaccination
campaign during the September-April influenza season or year-round, depending on the policies
and procedures of the dialysis facility. The value of this method is that the information collected
will assist facilities in identifying whether NHSN patients meeting criteria for influenza
vaccination are actually receiving vaccination, and the details of those vaccinations.
Additionally, dialysis facility staff will be able to identify specific gaps in adherence and
recommend changes in practices to ensure that all eligible patients are being vaccinated.
Settings: This is a facility-wide surveillance in which all maintenance dialysis patients greater
than 6 months of age are monitored during the selected month(s).
Requirements: Surveillance consists of a review of all maintenance dialysis patients greater
than 6 months of age facility-wide to determine whether those patients who meet criteria for
influenza vaccination are offered and receive influenza vaccination. Surveillance must be
conducted for at least one calendar month during the influenza season as indicated in the Dialysis
Monthly Reporting Plan (CDC 57.501). During seasons when seasonal and non-seasonal subtype
vaccinations are recommended, such as 2009/2010, monitoring is required for all influenza
vaccinations and dialysis facilities offering both season and non-seasonal vaccinations should
report denominator data for each vaccination subtype (i.e., seasonal or non-seasonal) separately.
Patients requiring a second vaccine should not be included in the count of those previously
vaccinated. A Dialysis Patient Influenza Vaccination Denominator form (CDC 57.506) and a
Dialysis Patient Influenza Vaccination form (CDC 57.505) need to be completed for each of the
2 doses given. (See latest CDC/ACIP recommendations for current season details). Ideally, the
facility should conduct surveillance during each month of the influenza season (September
through April).
Monthly surveillance requires determination of the number of maintenance dialysis outpatients
greater than 6 months of age in the following categories for the month selected for review and
submission of two separate denominator forms for each surveillance month if the facility offers
both seasonal and non-seasonal vaccines. (All box numbers refer to the boxes found on the
Dialysis Patient Influenza Vaccination Denominator form [CDC 57.506]):

For the first month of your vaccination campaign, report the total patient census, separated
by patient dialysis modality. In subsequent months of your vaccination campaign, count
only new patients, by patient dialysis modality. (Only include patients 6 months or older.)

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Dialysis Patient Influenza Vaccination Protocol

Complete a Dialysis Patient Influenza Vaccination form (CDC 57.505) for each patient in the
facility during the surveillance period. For those patients who decline influenza vaccination,
reasons for declination (medical contraindications and personal) are captured (Table 2).
Table 2: Examples of Medical Contraindications to Influenza Vaccination and of
Personal Reasons for Declining Influenza Vaccinations
Medical Contraindications
Allergy to vaccine components
History of Guillain-Barré syndrome within 6 weeks of
previous influenza vaccination
Current febrile illness (Temp >101.5°)
Personal (non-medical) reasons for Fear of needles/injections
declining vaccination
Fear of side effects
Perceived ineffectiveness of vaccine
Religious or philosophical objections
Concern for transmitting vaccine virus to contacts

Definitions: All box numbers refer to the boxes found on the Dialysis Patient Influenza
Vaccination Denominator form (CDC 57.506).


For the first month of your vaccination campaign, report the total patient census, by patient
dialysis modality. In subsequent months of your vaccination campaign, count only new
patients, by patient dialysis modality. (Only include patients 6 months or older.)

Numerator and Denominator Data: Numerator data are reported on the Dialysis Patient
Influenza Vaccination form (CDC 57.505) (refer to the tables of instructions for completion
details). Denominator data are reported on the Dialysis Patient Influenza Vaccination
Denominator form (CDC 57.506) (refer to the tables instructions for completion details).
Data Analysis: Data aggregated across the entire facility are stratified (e.g., month, influenza
subtype, influenza season, and patient dialysis modality). Table 3 shows the formulas for metrics
that can be calculated.

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Dialysis Patient Influenza Vaccination Protocol

Table 3: Formulas for Metrics:
Data come from two CDC forms:
Boxes 1 - 4 of the Dialysis Patient Influenza Vaccination Denominator form (CDC 57.506)
Dialysis Patient Influenza Vaccination (DPIV) form (CDC 57.505)
Metric
Patient Vaccination Formula (x 100)
1

Prevalence rate for patients not
previously vaccinated among all
patients
2 Adherence rate for offering
influenza vaccination to patients
among all eligible patients
3 Adherence rate for receiving
influenza vaccination patients
among all patients
4 Influenza vaccination
administration adherence rate
among all medically eligible
patients
5 Influenza vaccination
administration adherence rate
among all medically eligible,
willing patients
6 Declination rate for patients
eligible for influenza vaccination
among all patients offered vaccine
7 Declination rate due to personal
(non-medical) reasons for patients
eligible for influenza vaccination
among all patients offered vaccine
8 Declination rate due to medical
contraindications for patients
eligible for influenza vaccination
among all patients offered vaccine
9 Failure rate for offering vaccine to
patients medically eligible for
influenza vaccination among all
medically eligible patients
10 Prevalence rate of all patients
previously vaccinated among all
patient admissions

June 2013

Box 4
Box 1
Total # DPIV Forms “Vaccine offered” = “Yes”
Box 4
Total # DPIV Forms “Vaccine administered” = “Yes”
Box 4
Total # DPIV Forms) “Vaccine administered” = “Yes”
Box 4 – Total # DPIV Forms “Vaccine declined” = “Yes”
due to medical contraindications
Total # DPIV Forms “Vaccine administered” = “Yes”
(Box 4 –Total # DPIV Forms “Vaccine declined = “Yes” due
to medical contraindication) + “Vaccine declined” = “Yes”
due to personal reasons
Total # DPIV Forms “Vaccine declined” = “Yes”
Total # DPIV Forms “Vaccine offered = “Yes”
Total # DPIV Forms
“Vaccine declined” = “Yes” due to personal reasons
Total # DPIV Forms “Vaccine offered” = “Yes”
Total # DPIV Forms
“Vaccine declined” = “Yes” due to medical contraindications
Total # DPIV Forms “Vaccine offered”= “Yes”
Box 4 – Total # DPIV Forms “Vaccine offered” = “Yes”
“Vaccine declined” = “Yes” due to medical contraindications
Box 3
Box 1

Dialysis Patient Influenza Vaccination Protocol

References
1.
Simonsen L, Reichert TA, Viboud C, Blackwelder WC, Taylor RJ, Miller MA. Impact of
influenza vaccination on seasonal mMortality in the US elderly population. Arch Intern Med.
2005;165(3):265-72.
2.
Thompson WW, Moore MR, Weintraub E, Cheng PY, Jin X, Bridges CB, et al.
Estimating influenza-associated deaths in the United States. Am J Public Health. 2009;99 Suppl
2:S225-30.
3.
Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, et al.
Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA.
2003;289(2):179-86.
4.
Thompson WW, Weintraub E, Dhankhar P, Cheng PY, Brammer L, Meltzer MI, et al.
Estimates of US influenza-associated deaths made using four different methods. Influenza Other
Respi Viruses. 2009;3(1):37-49.
5.
Barker WH. Excess pneumonia and influenza associated hospitalization during influenza
epidemics in the United States, 1970-78. Am J Public Health. 1986;76(7):761-5. PMCID:
1646876.
6.
Barker WH, Mullooly JP. Impact of epidemic type A influenza in a defined adult
population. Am J Epidemiol. 1980;112(6):798-811.
7.
Monto AS, Kioumehr F. The Tecumseh Study of Respiratory Illness. IX. Occurence of
influenza in the community, 1966--1971. Am J Epidemiol. 1975;102(6):553-63.

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Dialysis Patient Influenza Vaccination Module

Instructions for the Dialysis Patient Influenza Vaccination form (CDC 57.505)
*Indicates a required field.
^Indicates a conditionally required field.

Data Field
*Facility ID

Instructions for Data Collection
Required. The NHSN-assigned facility ID number will be auto-entered by
the computer.
*Event #
Required. Event ID number will be auto-entered by the computer.
*Patient ID
Required. Enter the alphanumeric patient ID number. This is the patient
identifier assigned by the dialysis center and may consist of any combination
of numbers and/or letters.
Social Security #
Optional. Enter the 9-digit numeric patient Social Security Number.
Secondary ID
Optional. Enter the alphanumeric ID number assigned by the facility.
Medicare #
Optional. Enter the patient’s Medicare number.
Patient name
Optional. Enter the last, first, and middle name of the patient.
*Gender
Required. Select Female, Male or Other to indicate the gender of the
patient.
*Date of Birth
Required. Record the date of the patient birth using this format:
MM/DD/YYYY
Ethnicity
Optional. Specify whether the patient’s ethnicity is Hispanic or Latino.
Race
Optional. Specify the following that identify the patient’s race: American
Indian/Alaska Native; Asian; Black or African American; Native
Hawaiian/Other Pacific Islander; and White.
*Event Type
Required. FLUVAX.
*Influenza subtype
Required. Check one:
 Seasonal
 Non-Seasonal
If patient received both vaccines, complete two separate forms (one for
information regarding the seasonal vaccine and one for information
regarding the non-seasonal vaccine).
*Flu Season
Required. Enter (or select from the pull-down menu) the fall to spring year
range for the flu season being reported.
*Patient Dialysis
Required. Check one:
Modality
 In-center hemodialysis
 Home hemodialysis
 Peritoneal dialysis
*Patient vaccinated in Required. Indicate whether the patient was vaccinated in your dialysis
this facility
facility.
*Patient previously
Required. Indicate whether the patient was previously vaccinated elsewhere
vaccinated elsewhere for the flu season.
*Patient declined
Required. Indicate whether the patient declined the vaccine for any reason.
vaccine

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Dialysis Patient Influenza Vaccination Module

^Reason(s) vaccine
declined
^Date Vaccine
Administered
^Type of influenza
vaccine administered

Manufacturer
Lot number
^Route of
administration
Vaccine Information
Statement
Edition Date
Vaccinator ID

Title
Name
Custom Fields

Comments

June 2013

Conditionally required. If answered “Yes” to “Patient declined vaccine,”
required to complete either section A or B. May not complete both sections.
If both sections are applicable to the patient, only complete section A.
Conditionally required. If answered “Yes” to “Patient vaccinated in this
facility” or “Yes” to “Patient vaccinated elsewhere for this flu season,”
required to enter date vaccine administered using this format: mm/dd/yyyy.
Conditionally required. If answered “Yes” to “Patient vaccinated in this
facility” or “Yes” to “Patient previously vaccinated elsewhere for this flu
season,” required to enter the type of vaccine administered. For this section,
complete information regarding the influenza subtype selected in the
“Influenza subtype” field at the top of the form. Only mark “Other
(specify)” if the influenza type administered is not listed. If mark “Other
(specify),” list the brand name or type administered.
If patient received both season and non-seasonal influenza vaccines,
complete two separate vaccination forms, one for each vaccine subtype.
Optional. If answered “Yes” to “Patient vaccinated in this facility,” enter the
name of the vaccine manufacturer.
Optional. If answered “Yes” to “Patient vaccinated in this facility,” enter the
vaccine’s lot number.
Conditionally required. If answered “Yes” to “Patient vaccinated in this
facility” or “Yes” to “Patient previously vaccinated elsewhere for this flu
season,” required to check one: Intramuscular or Subcutaneous.
Optional. Indicate whether the Vaccine Information Statement (VIS) was
provided to the patient.
Optional to enter the edition date of the vaccine information statement
provided to patient. Enter date in the format: MM/DD/YYYY
Optional. If vaccine is administered, indicate the vaccinator’s identifier.
This is an identifier assigned by the facility and may consist of any
combinations of numbers and/or letters.
Optional. If vaccine is administered, indicate the vaccinator’s identifier.
Optional. If vaccine is administered, indicate the last, first, and middle name
of the staff member who administered the vaccine.
Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MM/DD/YYYY), numeric, or
alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom Options
section of NHSN before the field can be selected for use. CDC does not
typically analyze these data.
Optional. Use this field to add any additional information about this
vaccination that would help you to interpret your surveillance data. CDC
typically does not analyze these data.

Dialysis Patient Influenza Vaccination Module

Instructions for the Dialysis Patient Influenza Vaccination Denominator form
(CDC 57.506)
*Indicates a required field.
Data Field
Instructions for Data Collection
*Facility ID
The NHSN-assigned facility ID number will be auto-entered by the
computer.
*Month
Required. Enter name of the month for which denominator count is
being reported.
*Year
Required. Enter the year for which the denominator count is being
reported in the format: YYYY.
*Vaccination type
Required. Influenza.
*Vaccination
Required. Choose one:
subtype
 Seasonal
 Non-Seasonal
If your facility intends to offer both seasonal and non-seasonal vaccines to
at least one patient, complete a separate denominator form for each
subtype each month.
*Number of dialysis Required. When completing the form for the first month of the
vaccination campaign, report the total patient census, separated by patient
Patients
dialysis modality. Include all patients who received one or more
treatments at any time during the month. Include only patients age 6
months and older.

Custom Fields

Comments

June 2013

For each month following the first month of the campaign, enter the
number of new patients, separated by patient dialysis modality. Include
only patients age 6 months and older.
Optional. Up to 50 fields may be customized for local or group use in any
combination of the following formats: date (MM/DD/YYYY), numeric,
or alphanumeric.
NOTE: Each Custom Field must be set up in the Facility/Custom Options
section of NHSN before the field can be selected for use. CDC does not
typically analyze these data.
Optional. Use this field to add any additional information about this
vaccination that would help you to interpret your surveillance data. CDC
typically does not analyze these data.