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Flu vaccination rates in HCWs: Room for improvement
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Compared with a 36% overall influenza vaccination coverage rate among health care workers in 2006, the mid-season coverage rate for 2012-2013 has increased to about 63% — on the path to nearing the Healthy People 2020 target goal of 90%, according to the CDC.
As of press time, influenza activity remains elevated in most areas of the United States after an early start to the season. “The only thing predictable about the flu is that it’s unpredictable. Only time will tell us how long our season lasts and how moderate or severe the season will be,” Thomas Frieden, MD, director the CDC, said during a recent media briefing on influenza activity in the United States.
Despite pleas from numerous organizations for all health care workers (HCWs) to get vaccinated against influenza — the CDC has recommended HCW influenza vaccination since 1981 — the rates remain low among those working in long-term care facilities (48.7%), among assistants/aides (43.4%) and nonclinical support staff (54.5%).
According to the most recent data from the CDC’s Internet Panel Survey on Health Care Personnel Flu Vaccination, the most common reasons for HCWs to not get the vaccine were “they do not want vaccination” and “they believe that vaccination is ineffective.”
William Schaffner, MD, said there are many institutions that have a mandatory influenza vaccination program in place across all hospitals and clinics.
Photo courtesy of Vanderbilt University
"Another reason [patients give for choosing to not get the vaccine] is that you can get ill from the vaccine and that there are side effects of various kinds, which blend into ‘you get flu from the flu vaccine,’” William Schaffner, MD, professor and chairman of the department of preventive medicine and professor of medicine in the department of infectious diseases at Vanderbilt University School of Medicine, told Infectious Disease News. “Considering that we give flu vaccine in the US alone to the tune of 120 million doses, obviously it can’t be that unsafe. We do this annually, never mind the doses that are given around the world.”
Schaffner also said patients who claim they have gotten influenza from a flu vaccine “is completely erroneous. You may get a sore arm or the nasal vaccine will give you a sore throat or a runny nose, but these are temporary inconveniences and are in no comparison to getting influenza, let alone transmitting it to an already ill patient.”
In an interview with Infectious Disease News, Edward J. Septimus, MD, FIDSA, FACP, FSHEA, medical director of infection prevention and epidemiology clinical services with HCA Healthcare System, said all health care professionals should set the platform for urgency around the fact that immunization is a patient safety issue.
“There needs to be education to dispel the myths about vaccination, which are still widely prevalent out there,” Septimus said.
Gregory A. Poland, MD, Director, Vaccine Research Group, Mayo Clinic, said that all HCWs should get the influenza vaccine.
“Influenza vaccines are not perfect, but they are the best preventive measure that we have,” Poland said in an interview with Infectious Disease News. “We should make [influenza vaccines] mandatory because it is a patient safety and quality of care issue. It’s not necessarily that we or someone else is trying to say that we know better about protecting your own health. It’s that we have standards and we place patient interests above our own interests and are willing to do anything within the realm of what’s safe to protect patients.”
Review essential interventions
In a recent viewpoint published in JAMA, Thomas R. Talbot, MD, and H. Keipp Talbot, MD, MPH, both of Vanderbilt University School of Medicine, said: “Following last year’s season of low activity, influenza is surging across the country. With influenza intensifying, it is important to review essential interventions that prevent influenza transmission at home, at work and in health care facilities.”
According to the researchers, there are key actions that should be undertaken to prevent the spread of influenza. While the basic infection control practices (hand hygiene, cough etiquette and social distancing) are important prevention methods, they said that additional measures to limit transmission of influenza in health care settings are essential.
Edward J.
Septimus
These additional measures include screening patients on arrival to the hospital to assess for respiratory symptoms, keeping infected patients away from other ill patients and ensuring that visitors and [HCWs] do not visit or work while ill — known as presenteeism.
“Influenza…is unique among respiratory viral pathogens in that another effective intervention to prevent transmission exists: Vaccination,” they wrote. “The increasing incidence of influenza across the United States should remind all clinicians about the key methods for transmission prevention, including vaccination. Misperceptions about influenza vaccine are common and often deeply rooted; for the protection of patients, colleagues, and loved ones, these perceptions must continue to be addressed, and the approach should be to immunize, immunize, immunize!”
Mandatory vaccination program feasible
“A key component of a successful vaccination program is that you have to have your executives on board — the local executive leadership helping to drive these programs,” Septimus said. “The top executives need to be onboard, health care workers need to be educated, and there has to be some accountability for patient safety.”
The first large, mandatory influenza vaccination program occurred at the Virginia Mason Medical Center (VMMC) in Seattle.
In a 2010 study published in Infection Control and Hospital Epidemiology, Robert M. Rakita, MD, clinical professor of medicine at the University of Washington, and colleagues report 5-year data on the vaccination program that mandated all HCWs to either get vaccinated or to wear a mask at work during influenza season. The program initially faced resistance, but eventually led to vaccination rates that remained above 98% since program implementation.
“They had a passionate senior administrator who was avid about patient safety, and they implemented their program in a very rigorous fashion,” Schaffner said. “They were very firm in their program and had to discharge some people who elected to not be vaccinated. There is always a fair amount of resistance during the first year of implementation, but by the third or fourth season, it’s all routine.”
Since that time, other hospitals have followed suit. At BJC HealthCare in St. Louis, vaccination rates reached 98.4% after mandatory implementation of the influenza vaccine.
Similarly, Hospital Corporation of America (HCA) achieved a 96.4% overall vaccination rate after introducing their policy during the 2009-2010 season. The program was multifaceted and required influenza vaccination but also allowed for declination of vaccination for any reason. HCWs that declined vaccination were then required to wear a mask.
“We teach cough etiquette and hand hygiene. All of this is part of an influenza bundle that we certainly have advocated in our program,” Septimus said. “It’s not just about vaccines. Vaccines are only a part of it.” He said an effective flu program needs to be multifaceted. HCA’s program includes:
- Healthcare Workers: Seasonal flu vaccination; stay home when ill; select appropriate personal protective equipment when caring for known or suspected flu cases; and appropriate use of antiviral medications.
- Patients: Early recognition, separation and droplet precautions for suspected or confirmed cases; surgical masks when being transported; and use effective antiviral medications.
- Everybody: Compulsive hand hygiene and compulsive respiratory etiquette.
Besides these patient safety initiatives, Septimus and colleagues across HCA institutions set up an influenza Gmail account, in which any HCW could send in questions that would be answered 24/7. Subject content experts were there to answer all questions immediately.
“There are many institutions, including HCA, that have instituted a program across all hospitals and clinics that are going smoothly,” Schaffner said. “I believe it’s because they are very rigorous.”
At Schaffner’s institution, Vanderbilt University Medical Center in Tennessee, a committee has been assigned to implement a universal influenza vaccination program. Schaffner said the committee is working to learn from the many other institutions that have mandatory programs established. “We are currently working on all the elements of the program. Exactly what form it will take is unclear,” he said.
Reduction in employee absence rates
During a presentation at the most recent ID Week meeting in San Diego, Heather Young, MD, of the Denver Health Medical Center, presented findings from a study that assessed the implementation of a universal influenza vaccination policy in 2011.
According to background information in the study, about 25% of HCWs contract influenza each year, and in turn, employee absence rates increase during influenza season. The policy required all HCWs and contractors with direct contact with patients to be vaccinated with the influenza vaccine by Dec. 1, 2011. Influenza activity rates were compared between the 2006-2007 and 2011-2012 influenza seasons. Both seasons were classified as mild and with low activity by the CDC.
For the 2011-2012 influenza season, 98% of HCWs received influenza vaccination. Compared with a mean HCW absence rate of 9.14 per 100 employees during 2006-2007, the absence rate was 6.15 per 100 employees per month in 2011-2012 (P=.0004).
“Universal influenza vaccination was associated with lower employee absences in 2 years with comparable low influenza activity. The data suggest that universal influenza vaccination may keep the workforce healthier,” Young told Infectious Disease News.
Medical societies back mandatory vaccination
In 2010, the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America endorsed mandatory vaccination policies for all HCWs to reduce the risk for infection between patients and employees.
“SHEA views influenza vaccination of [health care personnel] as a core patient and [health care personnel] safety practice with which noncompliance should not be tolerated,” wrote researchers representing SHEA. “It is the professional and ethical responsibility of [health care personnel] and the institutions within which they work to prevent the spread of infectious pathogens to their patients through evidence-based infection prevention practices, including influenza vaccination.”
According to the two organizations, the only exceptions should include people with medical contraindications for receipt of the vaccine. In several studies, results indicated that a 100% vaccination rate among health care personnel in acute care settings triggered a 43% decline in risk for influenza among patients. This decrease appeared even higher — 60% — among nursing home patients, the panel wrote. Furthermore, other study data highlighted the cost-effectiveness of HCW vaccination as a prevention strategy.
HCWs as advocates
With the proper education, monitoring and access to free vaccination, HCWs have the ability to be advocates for the influenza vaccine for their patients — to lead by example.
According to Schaffner, it is important for clinicians to be vaccine advocates. “Annual immunization against influenza by health care workers is both a professional and ethical responsibility and it should be clearly accepted and undertaken with enthusiasm. It is a patient safety issue,” he said. “There is both an ethical and professional reason to get vaccinated — no excuses.
“Underlying it all, our colleagues in occupational health service and we in infection control are concerned that people do not have a sufficient understanding that this is a patient safety issue. They are only thinking in terms of personal protection rather than patient protection. They would accept the vaccine if patient protection were a more dominant thing on their minds,” he said.
Poland said that there are millions of patients across the nation who are sick with the flu and if HCWs are not protected, they get infected. “If that happens, they’ll spread it to other vulnerable patients and other staff members. We then have to say, requirements for influenza vaccination make the point that it isn’t about you, it’s about the patient.” — by Jennifer Henry
References:
Rakita R. Infect Control Hosp Epidemiol. 2010;31:881-888. Septimus E. JAMA. 2011; 305:999-1000.
Talbot TR. JAMA. 2013;doi:10.1001/jama. 2013.453. Young H. #95. Presented at: ID Week; Oct. 17-21, 2012; San Diego.
For more information:
William Schaffner, MD, can be reached at Preventive Medicine; 1500 21st Avenue South, Ste 2600; Nashville, TN 37212; email: william.schaffner@vanderbilt.edu.
Edward A. Septimus, MD, can be reached at 4257 Albans Street; Houston, TX 77005; email: eseptimus@gmail.com.
Heather Young, MD, did not provide contact information.
Disclosures: Poland is the chair of a Safety Evaluation Committee for investigational vaccine trials being conducted by Merck Research Laboratories. Poland offers consultative advice on vaccine development to Avianax, CSL Biotherapies, Dynavax, Merck & Co. Inc., Novartis Vaccines and Therapeutics, PAXVAX Inc., and Sanofi Pasteur. These activities have been reviewed by the Mayo Clinic Conflict of Interest Review Board and are conducted in compliance with Mayo Clinic Conflict of Interest policies. Schaffner and Septimus report no relevant financial disclosures.
Perspective
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Theodore C. Eickhoff, MD
Yes, there is room for improvement — in many facets of this issue. Acute care hospitals are doing a fine job in bringing influenza vaccination of HCWs into the 90% and above range, and they are to be commended. One point emphasized by Ed Septimus is the need for administrative buy-in and support for a program to be successful. Our own experience in my hospital underscores that point.
Long-term care facilities are clearly doing much less well in HCW vaccination, and this setting may represent even more of a patient safety concern. This should have a major push, and it’s not yet clear how it will happen.
Whether it is ethical or not for a hospital to terminate an employee for influenza vaccine refusal is often a troublesome issue. For new hires who know from day 1 that influenza vaccine is mandated, there should be little resistance, and I suspect the issue will quickly disappear. For longer term employees, the conditions of their employment contract have been changed by the influenza vaccine mandate — without their consent — and here the ethical issue is much more apparent. Certainly there are a number of approaches to this issue, such as masking during patient care that would not require termination. Does it really make sense to terminate a valued employee for refusal to take a vaccine that is agreed to be only 60% to 65% effective?
I find myself troubled by this issue from time to time. We — the flu vaccine establishment — academia, government, and pharma — have taken one of our least effective vaccines (hemagglutinen-based vaccine produced in eggs) and turned it into a virtually universal use vaccine. And it’s not just one time only, but repeated annually! Does this make sense? Have we seriously oversold influenza vaccine in this country and elsewhere in the world? Thoughts such as these are beginning to be heard from time to time, and perhaps it’s time to listen carefully to what is being said. For starters, I would urge readers to read through Mike Osterholm’s monograph published last fall, The Compelling Need for Game Changing Influenza Vaccines.
Perspective
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Michael Osterholm, PhD, MPH
If you are a health care worker, I surely recommend that you get vaccinated for influenza. But as the late Paul Harvey, famed radio commentator, would say, “Now, here is the rest of the story.”
Dr. Eickhoff, in his perspective, sets the stage for the “real discussion” we need to have about mandatory influenza vaccination of health care workers; namely, the effectiveness of our current influenza vaccines. As Dr. Eickhoff noted, the Center for Infectious Disease Research and Policy (CIDRAP) at the University of Minnesota recently published the most comprehensive cradle-to-grave review of influenza vaccines ever undertaken. That study, referred to as the CIDRAP Comprehensive Influenza Vaccine Initiative (CCIVI), provided several very important findings that are critical in considering the issue of mandatory health care worker vaccination. (The study can be accessed at http://www.cidrap.umn.edu/cidrap/center/mission/articles/ccivi-landing.html.)
First, straightforward and simple: Public health for many years consistently overstated the effectiveness of our currently licensed vaccines. Even now, the WHO position statement on influenza vaccines, published in November 2012, states that influenza vaccine is 70% to 90% effective in people younger than 65 years when the vaccine and circulating strain are closely matched. The statement quotes a secondary source, the US Advisory Committee on Immunization Practices (ACIP), to support this claim. In our CCIVI report, we identified 30 instances in which the latest ACIP influenza vaccine statement did not apply current standards of scientific rigor to their analysis or did not cite relevant work. In each instance the efficacy or effectiveness of the vaccine was overstated. More specifically, the 2006 statement on influenza vaccination of health care workers from the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the ACIP cites four studies as providing Category 1A evidence that supports the reduction of morbidity and mortality among patients as the result of health care worker influenza vaccination. Our review found that only two of the studies provide even limited support for the HICPAC and ACIP statement, and the other two provided no support. Yet these studies are frequently cited by supporters of mandatory influenza vaccination. And no other studies have been offered to support this position. In short, while it makes logical sense that mandating influenza vaccination of health care workers will reduce transmission of influenza to patients, the data to support that conclusion are thin to nonexistent. While public health often has to make recommendations regarding interventions without “air-tight” data, in this case, the strength of that recommendation far exceeds any such data.
Second, in our 2012 meta-analysis of current influenza vaccines (which was included in the CCIVI report) published in Lancet Infectious Diseases, we found that trivalent inactivated influenza vaccine provides moderate protection (59%) against virologically confirmed influenza in young healthy adults, but such protection is greatly reduced or absent in some seasons. In fact, through the midpoint of this season, study results from the CDC and from researchers in Europe and Canada show that, despite a close match between the H3N2 component of the 2012-13 influenza vaccine and the currently circulating H3N2 influenza strain, vaccine effectiveness is only 45% to 55% in study participants, primarily younger adults.
Based on these vaccine efficacy and effectiveness data, one can begin to understand there is a fundamental flaw with the logic behind mandatory health care worker vaccination. Assuming that 80-90% of health care workers will agree to be vaccinated with a voluntary program, mandatory vaccination programs are really all about the remaining 10-20% of workers. It’s among this latter group that steps to mandate the use of masks with patient care and even dismissal have been used. Yet, they are not the group of health care workers that pose the greatest risk of influenza transmission to patients. It’s the 45% to 55% of health care workers who are vaccinated and who remain susceptible to infection. There are data from recent well-designed studies which support that individuals who are influenza vaccine failures do not pose less risk of transmission or have milder illness. Should we make all health care workers wear masks during the influenza season if we really are concerned about patient safety? Or why not require mandatory exclusion of any health care worker with respiratory signs and symptoms if we are truly trying to minimize patient exposure to potentially life-threatening respiratory agents? Also, does the current vaccine effectiveness data help explain why we don’t have convincing evidence as to the impact of influenza vaccination of health care workers on transmission of influenza to patients? I think our current approach is more like fixing three of the five screen doors on your submarine, but expecting a smooth and uneventful voyage.
It seems illogical to me that we have highly effective childhood vaccines that we know are responsible for a dramatic reduction in serious childhood diseases, yet we don’t truly make these mandatory for school attendance because of various opt-outs. Have we misplaced our data-driven public health priorities when we fire a health care worker for not being vaccinated for influenza, but allow children not vaccinated against measles to attend school?
It’s time to take a step back and reassess our approach to the control of influenza, without preconceived notions or the emotion of a cause. What do the data tell us, and how does this effort square with our other public health efforts? Until we get more effective influenza vaccines, we are not leveraging our public health tools with effectiveness or scientific honesty.
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