The Joint Commission Update for Infection Control

As flu season hits, remember new Joint Commission immunization standard for health care workers

National groups decry abysmal record of laggard rates

As the 2007-2008 flu season strikes, infection control and employee health professionals are reminded that a new Joint Commission standard requiring accredited organizations to offer influenza vaccinations to staff now is in effect. The Joint Commission requires that all accredited hospitals and long-term care accreditation programs:

  • establish an annual influenza vaccination program that includes at least staff and licensed independent practitioners;
  • provide access to influenza vaccinations on site;
  • educate staff and licensed independent practitioners about flu vaccination; nonvaccine control measures (such as the use of appropriate precautions); and diagnosis, transmission, and potential impact of influenza;
  • annually evaluate vaccination rates and reasons for nonparticipation in the organization's immunization program;
  • implement enhancements to the program to increase participation.

The Joint Commission's new standard stops short of setting a required percentage of immunizations or requiring declination statements for those who decline the vaccine. However, surveyors will expect to see immunization rates to be rising as part of enforcement of the standard. The Joint Commission joins several other organizations in addressing the historic problem of laggard staff immunization rates in the health care population. The Association for Professionals in Infection Control and Epidemiology has come out in favor of mandatory seasonal flu vaccinations for patient caregivers; the Society for Healthcare Epidemiology of America is calling for workers to sign off on declination statements if they turn down the shot; and the Centers for Disease Control and Prevention also puts declination statements on the table as an option.

There is no shortage of vaccine, as manufacturers are expected to increase last year's total by 12 million and distribute 132 million flu vaccine doses this season. Yet less than half of health care workers get the annual shot, citing a range of reasons and myths that have dogged the issue for decades. Some mistakenly think the vaccine can somehow give them the flu, while others do not understand they can transmit influenza before the onset of symptoms. There was little sympathy for this lingering mindset at a recent news conference at the National Foundation for Infectious Diseases in Bethesda, MD.

"We cannot be complacent [about] health care workers who fail to get the vaccination. It protects the personnel and their families," said Julie Gerberding, MD, MPH, director of the Centers for Disease Control and Prevention. "Also, it works in the opposite direction — the health care worker brings the virus to work, and puts patients at risk. It's unconscionable that they don't receive the influenza vaccine."

Consequently, unvaccinated health care workers not only risk contracting flu, but also can transmit the disease to patients and family members. "Many health care workers simply state, 'When I get sick, I'll stay home; I won't make others sick," said William Schaffner, MD, chairman of the department of preventive medicine at the Vanderbilt University School of Medicine in Nashville, TN. "However, the day before you feel sick, you are already covering your patients with the influenza virus."

Jeanne M. Santoli, MD, MPH, deputy director of the immunization services division at the CDC, stated that only 40% of health care workers receive vaccinations in anticipation of the influenza season. (Likewise, only 20% of caregivers in general receive an influenza vaccine according to Kerry Weems, acting administrator of the Centers for Medicare & Medicaid Services.) Unfortunately, health care workers are also subject to the illness regardless of present health. "Some people think they are very healthy and are not aware of the risk of infection," said Santoli. "There is a knowledge gap."

'We don't need wounded healers'

In a separate interview, Robert M. Jacobson, MD, chairman of the department of pediatrics and adolescent medicine at the Mayo Clinic in Rochester, MN, emphasized that health care workers should not report to work if they have flu symptoms. "We don't need wounded healers," he said. "If you can't control your secretions, stay at home. It's not a badge of honor."

Jacobson has written editorials emphasizing his belief that all health care workers should be vaccinated. "It should be universal and required," he said. "Anyone working in a health care institution, whether on the phone, working with test tubes, or greeting patients should be vaccinated. We need to protect our patients and it is proper role modeling."

Unvaccinated health care workers not only risk contracting and experiencing influenza, but also can transmit the disease to patients and family members. A person with influenza is contagious for up to five days after infection, and children remain contagious for up to 10 days after infection with the virus.

This has particular impact upon the most vulnerable patients, including the elderly, patients with chronic health conditions such as asthma and diabetes, infants and children, and pregnant patients. Specifically, children have been known to be primary carriers of the disease in the general community. "Children are often in larger groups while the elderly rarely are," said Jacobson.

Influenza vaccination of health care workers also assists in supporting the immunity of patients who cannot receive vaccination due to egg allergy. The "halo effect" is provided to a susceptible patient by vaccination of family, friends, and those in contact with the unvaccinated person. The influenza vaccine available this year, in both injection and nasal spray forms, will cover three strains: Influenza B, H1N1, and H3N2, which were the most common at the end of last season. Although identification of the exact strain to affect this season is an unknown, receiving an influenza vaccination will minimize the extent of illness once contracted regardless of strain. The vaccine nasal spray is contraindicated in pregnant women.

Health care workers need to be aware of the serious nature of influenza, which can lead to fever, cough, chills, fatigue, and muscle pain. Influenza should not be confused with stomach flu although children also may experience nausea and vomiting. An advanced state of influenza can lead to pneumonia, dehydration, bacteremia, meningitis, myocarditis, rhabdomyolysis, encephalopathy, and encephalitis, prolonged seizures, and renal failure. An estimated 36,000 people die of influenza annually.

The risk of health care worker exposure is great, since the majority of people still do not elect to receive an influenza vaccination. The highest rate of vaccination is in the senior population with 69% of those who are 65 years and older getting an influenza shot, according to Santoli. The statistics for other patient populations are worse: only 37% of those between the ages of 50 to 64 years and 31% of those at high risk in the 18- to 49-year-old age group reported receiving a flu shot. "In the pediatric population, only about one third of those aged 6 to 23 months received a flu shot in 2005-2006. Only two thirds received the full dose," said Santoli. "In all children less than 2 years old, only one fifth were fully protected."

The influenza vaccination rate in children is not surprising to Jacobson though, given that it is a relatively new indication in this patient population and the time-dependent nature of the vaccination. "The problem with the influenza vaccine, unlike all other vaccines, is that this one has to be given during flu season," said Jacobson.

To minimize exposure to patients with influenza, health care workers should consider triaging and providing masks and hand disinfectants to contagious patients. If suspected flu patients cannot be isolated from common areas, they can also be provided with tissues and asked to cover their coughs, under the general "respiratory etiquette" guidelines recommended by the CDC. Surfaces that are possible sources for respiratory secretions should be disinfected as soon as possible.

Vaccinations should be offered until supplies or March, whichever comes first. The continuance of vaccination is important because a disease can revisit a community, said Santoli. "The peak of disease is January or February or even later," she said. "Not to vaccinate in December is a missed opportunity."

Ten tips to stop flu spread

At least one public health department (in Seattle and King County, WA) has specific rules on return to employment for those with influenza.

Workers who have had influenza are advised to wait to return to work for at least five days from onset of symptoms with resolution of fever and improvement of cough. Since mandating influenza vaccinations as a term of employment appears to be rarely required in institutions, action ultimately may come at the state level. Santoli said there has been some discussion about mandatory health care worker vaccination. The vaccination should extend beyond medical doctors and nurses to emergency department responders, technicians, and others who work in health care settings, she said. According to Santoli, 15 states have regulations regarding vaccination of health care providers in long-term care facilities. Three states require health care facilities to offer flu vaccine to health care providers, and three states require that health care providers get the influenza vaccine unless they have a religious, medical or philosophical reason not to do so. "Some states have laws in long-term care facilities where every patient is a high-risk patient," said Santoli. "There has been a lot of discussion among provider groups as well."