Ignorance 1: Education 0 Time to mandate flu shots

Voluntary vaccine approach has failed

Voluntary annual influenza immunization programs that use educational efforts and other incentives to vaccinate health care workers have been an abject failure, a leading proponent of mandatory flu shots said in Tampa at the annual conference of the Association for Professionals in Infection Control and Epidemiology (APIC).

"We have to acknowledge that voluntary immunization programs have never resulted in high immunization rates in any setting for any age at any time for any reason at any location with any vaccine," said Gregory D. Poland, MD, director of the vaccine research group at the Mayo Clinic in Rochester, MN. "It does not work. Those data are clear and unambiguous. We have got to get past this."

Moreover, decades of voluntary programs chock full of incentives and educational outreach have reached a level of diminishing and dismal returns: little more than one-third of health care workers bother to be vaccinated during any given flu season.

"I want to believe and you want to believe that education works," Poland said. "It does not when it comes to this topic. I am sorry, it doesn't work. I wish it were otherwise. No study has been able to demonstrate significant sustained [vaccination] increases for any sustained time period as a result of educational efforts. It is not the answer. This has failed as the only strategy we have had — trying to encourage people, provided free [vaccine and] education. It simply hasn't worked."

The health care system will "either lead or be lambasted" on the issue given trends for patient safety and empowerment, consumer demand for health care accountability, and increasingly negative press coverage.

"We have to take responsibility for this parade of deaths that happens year in and year out in our hospitals," Poland said. "Personal preference, I do not believe, is defensible in any way for a health care worker. We will be called to account here. Only 36%-40% are getting immunized each year. The vast majority of us are not getting the vaccine."

Given the situation, the APIC board of directors voted earlier this year to endorse mandatory influenza vaccination for health care personnel who have direct contact with patients. "I am just overjoyed that you took one of the early leadership positions in this and endorsed mandatory flu immunization," Poland told APIC attendees.

Ethical duty becoming a legal one

Health care workers and their employers have an ethical and moral duty to protect vulnerable patients from transmissible diseases, Poland said. "I believe they will have a legal duty, too, " he added, noting that flu vaccination for health care workers in acute care is now mandatory in seven states. Fifteen states mandate the shots for workers in long-term care, he said.

"There are now six lawsuits against physicians and health care institutions that failed to deliver the vaccine, and there was the suspicion that [flu was nosocomially] transmitted," Poland said. "You leave yourself vulnerable."

While short of a mandate, the current standard of care is requiring workers who decline flu shots to sign declination statements. "This should be seen as a matter of meeting professional and ethical standards, not personal preference," he said. "Unvaccinated health care workers should be excluded from direct patient care."

The situation is particularly disconcerting in an era of patient safety, when more and more public and media attention is focused on adverse outcomes in health care.

"Your colleagues do not necessarily understand," Poland said. "The reason for them to get vaccine is to protect somebody else. That is the primary reason — first, do no harm. It is a patient safety issue and a moral and ethical imperative. It is a win-win-win-win: the patient benefits, the employee benefits, the institution benefits, and the community benefits."

Poland cited numerous studies showing nosocomial transmission of influenza from unvaccinated workers to patients. "Influenza-infected health care workers transmit this deadly virus to their patients," he said. "A fact many of you do not know is that health care workers with asymptomatic influenza can transmit this virus to patients and to other staff. In fact, they can do so for about 24-36 hours before they develop symptoms or even if they never develop symptoms. Multiple studies show that about 70% of health care workers continue to work despite the fact that they are symptomatic for influenza."

Complications of influenza are particularly burdensome on certain subsets of patients, including children younger than 2 years old. "Until recently I was not aware of this," Poland said. "They have a mortality rate as high as 15%. That is sort of stunning."

Poland cited a flu outbreak in an NICU in which a baby died after being exposed to infected health care workers. "This one is a tough one for me," he said. "Try to get your head around this. You go to a hospital to deliver your high-risk baby in the United States in 1998 — best health care system in the world, right? And your baby dies of an infection that was preventable by a $15 vaccine. In fact, for the health care worker, it wouldn't have cost anything at all."

Other vulnerable patient groups include the elderly, the immunocompromised, and critically ill patients. Patients acquiring flu in the hospital results in increased costs, extended lengths of stay, and death.

Surprisingly, nursing is the health care work segment with the greatest entrenched resistance to being vaccinated against flu, Poland said. "[Nurses] have consistently lower vaccination rates than any other group, and the big concern is that there is no other group of health care workers who have closer and more prolonged contact with patients," he said. "There are no data that show education changes this. Furthermore, nurses have more reasons for rejecting vaccine than all other health care workers and are more likely to believe it is not safe or effective."

'Ignorance is killing people'

The reasons typically given by health care workers for refusing the vaccine include that they never get the flu, pose no risk to patients, fear of vaccine side effects, fear of needles, or belief that the vaccine causes flu. The vaccine is safe and effective and does not cause the flu, Poland emphasized, adding that he personally conducted a study that showed that a sore arm at the immunization site is the only actual side effect that has statistical significance when comparing flu vaccine to a placebo.

Beyond the health care setting, flu is somewhat underappreciated as an infectious disease threat during a typical, nonpandemic year. Yet seasonal flu kills an average of 36,000 Americans annually, almost as much as breast cancer (40,000), and three times as many as HIV/AIDS (14,000).

"If I got up here today and announced we had discovered a safe and effective vaccine against breast cancer, do you think it would take me six decades to get 36% of the women of this room to take that vaccine?" Poland said. "One out of every 10,000 Americans that are alive today will be dead by next flu season because they didn't get a flu shot."

While it is not clear how many flu deaths are directly linked to health care, all evidence shows transmission is occurring. "We know from serologic studies that about 25% of health care workers each season actually have antibodies that show that they are infected with one of the currently circulating strains," he said. "About 50% of the health care workers who have that evidence were unaware that they had influenza. One of the things that I hear a lot is that 'I never get the flu.' Yes you do, you just don't know it, and that ignorance is killing people."