The AAP recommends special efforts be made to vaccinate all health care workers.
Compared with a 36% overall influenza vaccination coverage rate among health care workers in 2006, the mid-season coverage rate for 2012-2013 increased to about 63% — on the path to nearing the Healthy People 2020 target goal of 90%, according to the CDC.
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%).
Infectious Diseases in Children Editorial Board member Pedro A. Piedra, MD, said he thinks those rates could be higher.
“All health care personnel by occupation and work setting can do much better in achieving influenza vaccination coverage of 90% or higher. Physician offices, ambulatory settings and support staff underachieve in influenza vaccination coverage compared to other health care occupations and work settings,” said Piedra, who is professor in the department of molecular virology and microbiology at Baylor College of Medicine. “Mandatory influenza vaccination among health care employees in the hospital setting has achieved influenza vaccination rates above the Healthy People 2020 target.”
Paul A. Offit, MD, chief of the division of infectious diseases and director of the Vaccine Education Center at CHOP, said that all HCWs should be vaccinated against influenza.
Photo courtesy of Children’s Hospital of Philadelphia
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.”
“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 Diseases in Children. “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 or HCWs who claim to 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.”
Piedra said these negative attitudes and misconceptions among HCWs must be addressed.
“Influenza vaccines are safe and well tolerated. They have good efficacy and reduce complications caused by influenza infection. Strong advocacy begins at work,” he said. “Vaccinating our health care personnel against influenza sends a strong message to the parents that we care about the health of their children.”
Patient safety first
In an interview with Infectious Diseases in Children, Edward J. Septimus, MD, FIDSA, FACP, FSHEA, medical director of infection prevention and epidemiology clinical services with HCA Healthcare System in Houston, said all health care professionals should set the platform for urgency around the fact that immunization is a patient safety issue.
Jeffrey R. Starke, MD, infection control officer at Texas Children’s Hospital and professor of pediatrics, section of infectious diseases at Baylor College of Medicine, agreed with Septimus and said patient safety should always be the first priority: “Our absolute covenant with our patients is to protect them.”
Starke, who is also an Infectious Diseases in Children Editorial Board member, said he believes that influenza and pertussis vaccines should be mandatory.
Gregory A. Poland, MD, director of the Vaccine Research Group at the Mayo Clinic in Rochester, Minn., also said 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 Diseases in Children. “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.”
Mandatory vaccination program feasible
The first large, mandatory influenza vaccination program occurred at the Virginia Mason Medical Center (VMMC) in Seattle.
According to Septimus, a key component of a successful vaccination program is to have the leadership on board to help drive these programs: “The top executives need to be onboard, HCWs need to be educated, and there has to be some accountability for patient safety.”
Piedra said mandatory programs have been shown to achieve outstanding influenza vaccination coverage among HCWs.
“Influenza vaccination of pediatric HCWs provides direct protective benefit, reduces the risk of influenza infection among health care workers and reduces the spread to children,” he said.
In a 2010 study published in Infection Control and Hospital Epidemiology, Robert M. Rakita, MD, clinical professor of medicine at the University of Washington in Seattle, and colleagues reported 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.
Similarly, HCA achieved a 96.4% overall vaccination rate after introducing its policy during the 2009-2010 season. The program was multifaceted and required influenza vaccination but also allowed declination of vaccination for any reason. HCWs who declined vaccination were then required to wear a mask.
Paul A. Offit, MD, chief of the division of infectious diseases and director of the Vaccine Education Center at Children’s Hospital of Philadelphia (CHOP), said CHOP currently has an influenza immunization rate of nearly 100%. CHOP instituted a mandatory policy in 2009, after which nine employees were fired. However, none of the hospital’s nearly 10,000 HCWs who receive annual immunization — defined as anyone who can walk the floors and potentially expose patients — have been fired since then for vaccine refusal.
“We do not consider it your inalienable right to catch and transmit a potentially fatal infection,” Offit said. “We think that if you choose to work in a health care facility, and choose to work around a vulnerable population of children, then you have taken on the responsibility to protect the patients.”
Medical societies back mandatory vaccination
Several professional organizations, including the AAP, the Pediatric Infectious Diseases Society, Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America (SHEA), have endorsed mandatory vaccination policies for all HCWs to reduce the risk for infection between patients and employees.
In the AAP Policy Statement on the Recommendations for Prevention and Control of Influenza in Children for the 2012-2013 influenza season, the Committee on Infectious Diseases said pediatricians, nurses, and all health care personnel should promote influenza vaccine use and infection control measures. Special efforts should be made to vaccinate all health care personnel, according to the AAP.
Pedro A. Piedra
Researchers representing SHEA wrote: “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. 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.”
The only exceptions, according to SHEA, 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.
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,” Schaffner said.
Poland said there are millions of patients across the nation who are sick with influenza, 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 and Cassandra A. Richards
CDC. Health care personnel flu vaccination. Internet panel survey, United States, November 2012. Available at: www.cdc.gov/flu/fluvaxview/hcp-ips-nov2012.htm. (Last updated Dec. 3, 2012).
CDC. National early season flu vaccination coverage. United States, 2012-13 flu season. Available at: www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2012.htm. (Last updated Dec. 3, 2012).
Committee on Infectious Diseases. Pediatrics. 2012;130:780-792.
Quan K. Infect Control Hosp Epidemiol. 2012;33:63-70.
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.
Young H. Abstract #95. Presented at: ID Week; Oct. 17-21, 2012; San Diego.
For more information:
Paul Offit, MD, can be reached at CHOP, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104.
Pedro A. Piedra, MD, can be reached at Department of Molecular Virology & Microbiology, Baylor College of Medicine, One Baylor Plaza, MS BCM385, Houston, TX 77030.
Gregory A. Poland, MD, can be reached at firstname.lastname@example.org.
William Schaffner, MD, can be reached at Preventive Medicine; 1500 21st Ave., South, Suite 2600, Nashville, TN 37212; email: email@example.com.
Edward J. Septimus, MD, can be reached at 4257 Albans St., Houston, TX 77005; email: firstname.lastname@example.org.
Jeffrey R. Starke, MD, can be reached at Texas Children’s Hospital MC 3-2371 1102 Bates Street Houston, TX 77030.
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., 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. Offit, Piedra, Schaffner, Septimus and Starke report no relevant financial disclosures.
Additional interventions for influenza prevention
After last year’s season of low activity, this year influenza began surging across the country early in the season.
In a recent viewpoint published in the Journal of the American Medical Association, Thomas R. Talbot, MD, and H. Keipp Talbot, MD, MPH, both of Vanderbilt University School of Medicine in Nashville, Tenn., said essential interventions that prevent influenza transmission at home, at work and in health care facilities should be reviewed with health care workers (HCWs).
Key actions should be undertaken to prevent the spread of influenza each year, they said. Although the basic infection control practices (hand hygiene, cough etiquette and social distancing) are important prevention methods, they said additional measures to limit transmission of influenza in health care settings are essential.
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.
Edward J. Septimus, MD, FIDSA, FACP, FSHEA, medical director of infection prevention and epidemiology clinical services with HCA Healthcare System in Houston, said an effective influenza program must be multifaceted.
“We teach cough etiquette and hand hygiene. All of this is part of an influenza bundle that we certainly have advocated in our program,” he said. “It’s not just about vaccines. Vaccines are only a part of it.”
HCA’s program includes:
HCWs: 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,” said 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. “It’s because they are very rigorous.”
At Schaffner’s institution, 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 Diseases in Children.