HIN1 vaccine could heighten calls for mandatory flu shots for health workers
HIN1 vaccine could heighten calls for mandatory flu shots for health workers
'Swine flu' debacle of 1976 may undermine response
With more hospitals in recent years considering mandatory seasonal flu immunizations for health care workers, the rise and highly anticipated seasonal resurgence of H1N1 influenza A raises a compelling question: Will the first pandemic in 41 years add momentum to increasing calls to make flu immunization a condition of health care employment?
If an H1N1 vaccine is developed and cleared for use prior to the traditional flu season, certainly health care workers will be among the prime groups targeted for immunization. Though most traditionally refuse the seasonal shot, declining to be vaccinated during a pandemic could create a considerable stir among a press and public with increasing awareness of infection prevention and patient safety. Indeed, a 2005 paper advocating mandatory flu vaccinations for health care workers underscored that the longstanding flu immunization apathy among clinicians would simply not be tolerated if the annual virus had a more exotic profile.
"If we had a safe and effective vaccine against a newly emerging infection such as SARS or avian influenza now, would we allow health care workers to care for infected patients without having received the vaccine?" asked outraged epidemiologists.1 "Conversely, would we allow infected health care workers to care for uninfected patients? In fact, concerns about the ethics of such behavior would surface almost immediately. Yet, we allow precisely these situations to occur with a [seasonal] virus that kills 36,000 Americans every year."
Still, the widespread perception that H1N1 — pandemic or not — primarily is a mild infection could undercut immunization efforts even if a vaccine is developed. Nevertheless, certain vulnerable patient populations will be at high risk of complications of infection if they are not immunized. The CDC recently reported three H1N1 deaths of obese patients, suggesting the virus could pose a particular risk to that patient group.2 The presence of such high-risk groups and the anticipated widespread circulation of the virus in more favorable fall conditions could put considerable pressure on hospitals and individual health care workers to be immunized if a vaccine is available. Moreover, health care-associated influenza outbreaks are not traditionally confined to just high-risk settings such as bone marrow transplant (BMT) units.
"Some people think this happens only in special units with very immunocompromised patients," said Thomas Talbot, MD, MPH, hospital epidemiologist at Vanderbilt University Medical Center in Nashville. "'It's just the BMT unit — the NICU.' It's not. I guarantee you can go to the literature and find a [flu] outbreak in just about any kind of care setting you can think of — general medicine, general pediatrics, ER, outpatients . . ."
At the very least, a snubbed pandemic vaccine would highlight the rather shocking apathy with which health care workers view annual flu shots. The CDC has had a standing recommendation to immunize health care workers against seasonal flu for more than a quarter-century. Though the moral high ground clearly lies with those who argue that medical workers and their employers have an ethical duty to protect vulnerable patients from transmissible diseases, only some 40% of health care workers are vaccinated during any given flu season. Yet they remain paradoxically dedicated to work, as multiple studies have shown that many health care workers report to work despite the fact that they have flu symptoms. Regardless, health care workers with asymptomatic influenza can transmit the virus to patients and other staff. Indeed, the ease of global spread of H1N1 — some of it obviously from asymptomatic cases — drives home the infection prevention message that health care workers can endanger patients by spreading influenza before they begin having symptoms.
"The recognition that — with any influenza — health care workers can be asymptomatic and shed virus has been highlighted by this pandemic, which I think will provide more interest in examining mandatory vaccination," Talbot tells Hospital Infection Control & Prevention. "The reason that we recommend influenza vaccination is primarily because they can spread to others at high risk, not necessarily for their personal health benefit. This is why vaccination is important. We are vehicles for spreading influenza to others."
That said, the impact of an H1N1 vaccine could be complicated by the fact that it would likely be given separately from the seasonal flu shot, creating a scenario where health care workers could receive one immunization but not the other. Moreover, with little or no herd immunity against the novel strain, two H1N1 shots may be needed.
"While I do think that the novel H1N1 influenza pandemic will impact this year's seasonal influenza vaccination campaign, the impact could go in either direction," Talbot said. "The concern about influenza may increase uptake of seasonal influenza vaccination. Or the fact that in all likelihood health care workers may need three shots this year — one seasonal and two H1N1 — might cause people to forego the seasonal and just get the H1N1."
The swine flu pandemic that never was
However, there is a rather disastrous precedent to all this lurking off stage left that could sway public opinion to the side of resistant workers and hospitals. The "pandemic that never was" occurred in 1976, but still resonates enough to fuel skepticism about the public health response to the latest iteration of a "swine flu." The false-alarm immunization campaign of some 40 million people is now infamously remembered more for the side effects of the vaccine, including cases of paralysis caused by Guillain-Barre syndrome. A global pandemic never materialized, and the 1976 swine flu immunization campaign is now widely viewed as a public health disaster. That cautionary tale has certainly informed the public health and vaccine production response today, but there were some rather creepy public service announcements aired at the time that are now making their way on to the Internet. They show people dismissing the risk of the "swine flu" and then cut quickly to them lying in bed sick after presumably contracting it.
The whole 1970s episode could play into health care workers' traditional misgivings about the flu vaccine. Indeed, some argue it is one of the lingering causes of distrust of vaccines in general and flu shots in particular. The reason health care workers typically give for declining flu vaccination include fear of adverse reactions or that it will make them sick or actually give them the flu. Others claim conversely that flu is not serious. The other commonly cited reasons in worker surveys are fear of needles, a perception that the vaccine does not work, or the rather optimistic belief that the targeted recipient never contracts the infection.
"In 2007, we surveyed almost 3,500 of our employees who refused the influenza vaccine and they matched what's reported in the literature," said Nancy W. Gemeinhart, RN, MHA, CIC, manager of BJC Occupational health Services in St. Louis. "More than 25% of those declining thought they believed the vaccine would make them sick. Almost 25% wouldn't give us a reason at all, they just declined."
Facing such resistance, Gemeinhart and administrative colleagues of all stripes embarked on an ambitious program to make seasonal immunization programs mandatory — a condition of work at BJC. The results: a staggering total of 98.4% (25,561) of eligible workers were immunized last flu season, with only 321 (1.24%) meriting rigorously reviewed medical exemptions and 90 (0.35%) receiving religious exceptions.
"Overall, we had eight who chose not to comply with the policy and their employment was terminated," she said recently in Fort Lauderdale, FL, at the annual meeting of the Association for Professionals in Infection Control and Epidemiology (APIC). "We had a transformational change in our vaccination rates among our health care workers."
The emergence of a pandemic flu virus may finally shake some of the benign perceptions of seasonal influenza, which many may be surprised to learn is the leading cause of vaccine-preventable death in the United States every year. "It has been published in the literature and is well known that health care-associated transmission of influenza increases morbidity, mortality, and definitely the length of stay for our patients," Gemeinhart said. "Influenza occurs when there is high census, and due to employee illnesses, you will have levels of employee absenteeism. There are excess dollars of $1 to $3 billion in health care costs alone for influenza in the U.S. each year."
Thus, Gemeinhart and colleagues successfully made the case for mandatory influenza immunizations, methodically exploding the myths about vaccine safety and following in the difficult footsteps of a similar program undertaken at Virginia Mason Medical Center (VMMC) in Seattle. In what is thought to be the first hospital in the United States to take such action, Virginia Mason officials mandated annual flu shots as a condition of health care employment in 2005.
Talbot credited such programs for being "pioneers" in the mandatory vaccine movement. "They felt through their top leaders that [they] had a voluntary program that is not working," he told APIC attendees. "They basically said it's required. You work here; you get vaccinated. You can't sign a declination [statement] because declination goes against everything we're saying. It's a patient safety issue. There is no patient safety in signing a form saying you just don't want to do it. They are now at 98% [immunization rates]; so, if there is any question whether mandating the vaccine works — it works. Unquestionably, it's the most effective method we have to drive up health care personnel [vaccination] rates."
There are studies that indicate total patient mortality is significantly lower in sites where health care workers were vaccinated when compared to sites where routine vaccination was not offered to workers (10% vs. 17% and 14% vs. 22%).3,4 In short, worker flu vaccination is a patient safety issue. The ethical imperative argument may be viewed as "coercive" by those who counter that it is not applied in other situations affecting patients, Talbot noted.
"I often hear that that is coercive, we don't really do it for anything else," he said. "But that's not really true. There are other mandates. If a surgeon goes in the OR and just doesn't feel like scrubbing or using sterile field drapes, [that would be unacceptable.] I would argue that is 'mandated.' We have many [examples]. In my institution, you are required to document immunity to rubella and measles or you must get vaccinated. We don't 'require' hep B, but you are strongly encouraged to get it or you sign a form. And what about annual PPD [TB] testing?"
An immediate question that arises in mandating flu vaccination is how do you enforce it? Hospitals not willing to go the distance with a condition of work requirement may find the program undermined and "gamed" by determined health care workers. From their view, the mandate may be an invasion of civil liberties, reinforcing the perception that the institution values the health of patients above that of workers. Even if a large proportion of workers are vaccinated, IPs must insure standard precautions are followed and the perception of flu risk does not broaden into a general attitude of lax compliance. "You can't do this in a vacuum," Talbot said. "You can't just address flu by vaccinating."
Mandatory programs take careful planning and implementation or they can run aground quickly, warned Kelly Foreman, RN, an infection preventionist at Providence Alaska Medical Center in Anchorage, AK.
"Our hospital attempted a mandatory flu vaccination campaign last year," she said during the APIC flu session. "Three weeks into the campaign, my CEO had to recall the mandatory requirement — mostly due to [worker] union issues. For three weeks I did nothing else in my department and occ-health, answering phone calls and [wearing] a 'Kevlar vest' up on the units. It was not a good scene. People who would normally get the vaccination did not just because our hospital said, 'You will do this.'"
The hospital has stepped back to examine all of the issues, but still is considering it for the future, Foreman added. "I think if it doesn't [improve] next year, it may be mandatory," she said. "But I like how Virginia Mason and [BJC] did it too as a condition of employment, so that anyone from here [forward] that is hired has to have a flu vaccination."
- Poland GA, Tasha P, Jacobson RM. Requiring influenza vaccination for health care workers: Seven truths we must accept. Vaccine 2005; 23:2,251-2,255. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of healthcare workers on mortality of elderly people in long-term care: A randomized controlled trial. Lancet 2000; 355:93-97.
- Centers for Disease Control and Prevention. Intensive-Care Patients with Severe Novel Influenza A (H1N1) Virus Infection — Michigan, June 2009.
- Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of health care workers in long-term care hospitals reduces the mortality of elderly patients. J Infect Dis 1997; 175:1-6.
- Salgado CD, Giannetta ET, Hayden FG, et al. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004; 25:923-928.
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