H1N1 pandemic legacy may be mandatory flu shots for health care workers

Forces aligning to make seasonal shots a condition of work

Ruth CarricoThe ebbing H1N1 influenza pandemic could leave one lasting legacy for future patients: they will be a lot less likely to die of nosocomial flu transmitted by a health care worker.

Long debated and deferred, mandatory seasonal flu vaccinations for health care workers appears to be an idea whose time has finally come in the wake of the first pandemic in four decades. Everything from scaled-up manufacturing capacity to primed public awareness is now in place to make a long-standing goal of infection preventionists and patient safety advocates become a reality in the coming flu seasons.

In addition, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) voted Feb. 24 to expand the recommendation for annual influenza vaccination to include all people ages 6 months and older. The move to universal flu immunization signals the importance of preventing influenza across the entire population and increases pressure on health care workers, a group that has largely resisted standing CDC recommendations to be immunized for a quarter- century. Enough — many infection preventionists are now saying — is enough.

"Ensuring that you are taking the steps to prevent transmission of illness to patients — who have placed their trust in you to provide them with safe care — should be a condition of employment," says Ruth Carrico, PhD, RN, CIC, a veteran IP and assistant professor of health promotion and behavioral sciences at the University of Louisville (KY). "Look, when you are a health care worker, you are not going to be able to wear artificial nails and you're probably going to have to work on Christmas day and Mother's Day at some point in your career. So, get over it. It's the same thing with flu immunization."

It's generally estimated that less than half of health care workers take the annual flu vaccine, citing a mix of apathy, unfounded fears and persistent myths.

"For some reason, influenza vaccine has this cloud hanging over it undeservedly," Carrico says. "The reasons for pushback against immunization are not patient-centered. Health care workers will take the MMR [measles/mumps/rubella] vaccine, but will not take the flu shot. I'm incredulous."

For example, early in the pandemic — when no one could predict its impact on the health care system — the only H1N1 vaccine available was the live attenuated nasal "mist" version. Hospitals widely balked at the option, citing among the reasons a legitimate but somewhat paradoxical concern for the highest-risk patients. The historical resistance to flu immunizations by health care workers does not bode well for future pandemics and emergency responses, Carrico warns.

"Now we have seen how quickly things can get out of hand," she says. "Not only are you confronting a novel virus, but you have all this pushback against immunization. But we have been taking vaccine programs to businesses, demonstrating the business value and really changing the whole community approach to immunization. I think this could have a great cascade effect so that we see many more health care workers ready to get their flu shots."

'An irresponsible act'

Paul OffitNew York was among the states that moved early to mandate H1N1 vaccine for medical personnel, but dropped the effort amid legal challenges and a shortage of vaccine early in the pandemic. Other states and individual hospitals are expected to pick up the banner for the 2010-2011 vaccine, which will include H1N1 and two other strains. Several large health care organizations have adopted mandatory vaccination policies. Barnes-Jewish Hospital in St. Louis recently reported its mandatory program resulted in flu immunization of 98% of some 26,000 employees.1 Only 1.59% received exemptions (1.24% for medical reasons and 0.35% for religious reasons). Eight employees were terminated. An editorial accompanying the recently published study said other hospitals should consider mandates if they cannot achieve health care worker immunization rates of at least 90%.2

"Health care workers can and do transmit influenza to vulnerable patients, leading to illness, deaths, and nosocomial outbreaks," the editorial stated.3,4 ". . . [T]he arguments favoring influenza vaccination of health care workers as a key patient safety tool are ethically, scientifically, and financially compelling. . . . Intentions and principles do not protect patients; results are needed."

During the pandemic, some hospitals mandated immunization with what vaccine they had, either seasonal or the H1N1 shot.

"At our hospital this year, we required flu vaccine," says Paul Offit, MD, infectious disease chief at the Children's Hospital of Philadelphia. "This is a mandate, which is to say that if you choose not to get a vaccine, then you suffer a societal cost. In the case of this hospital, you lose your job."

A member of the ACIP panel, Offit sees more hospitals going to mandatory immunization polices in the wake of the pandemic.

"We have a vulnerable population at this hospital," he says. "Children who have cancer and are getting chemotherapy, children with neurologic diseases that are getting suppressant therapy, children on steroids for their asthma. They're vulnerable. They can't be vaccinated. They depend on the population around them to protect them. And I think that those children are our responsibility. We felt it was an irresponsible act on the part of health care workers not to get a vaccine."

It's not as if hospitals don't already have conditions of employment, including vaccines such as the aforementioned MMR.

"We require a number of things — vaccines are one of them," Offit says. "We made this [mandatory] decision and we are happy with it. I think other hospitals are making it, and the group of hospitals that are doing this will serve as leaders for the future."

Though Offit was initially somewhat skeptical about the threat of H1N1, the impact on children makes it difficult to dismiss this as a "mild" pandemic. (In truth, the death toll in a typical flu season is higher, but annual flu usually claims the elderly.) He takes cold comfort from "dodging-a-bullet" metaphors or conclusions that the health care system could have been decimated by a "less forgiving" virus.

"I don't see this as necessarily 'forgiving' when 11,000 or 12,000 people die, including 1,000 children," he says. "We haven't had more than 150 children die in any previous five years [nationally], so that is an increase of almost 10-fold. We certainly had children die in our hospital with influenza — more so than we've had in previous years. So, I don't see it as that forgiving."

Many hospitals such as Offit's had already achieved high immunization rates — at least by historical standards — by making elaborate efforts to coax and convince health care workers.

"We certainly tried," he says. "We got immunization rates up from years ago in the mid-30% range into the 80% range by educating, paying for it, making it very easy to get, having declination forms, videotapes. But we got stuck at the mid-80% range — and we'd had it. The fact of the matter is people die of this virus and we have a vaccine that can safely prevent it."

The anti-vaccine movement

One of the leading vaccine proponents in the nation, Offit sees the same misguided fears in health care workers suspicious of the annual flu shot as in parents in the growing anti-vaccine movement.

"It's the same animal, which is to say that there are a lot of myths circulating even among nurses who fear that the vaccine itself causes influenza; or that they took the vaccine and they still got influenza; or they got the vaccine and their whole family got influenza; or the vaccine is somehow dangerous," he says. "I think it reflects the general population."

The H1N1 vaccine has turned out to be perfectly safe, but the marked transparency with which it was tested and the implementation of an adverse reaction tracking system may have given the impression that officials feared another "swine flu" debacle.

"They put in a monitoring process that didn't exist before, but in terms of testing the vaccine they used the same procedures and methodologies they use each year," says Eric Toner, MD, a pandemic planning expert and a senior associate with the Center for Biosecurity at the University of Pittsburgh Medical Center. "They implemented a tracking process to look for adverse effects primarily because of what happened in 1976 with the swine flu vaccine."

The infamous false-alarm immunization campaign of some 40 million people is now 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 has cast doubt over flu shots ever since. That perception lingers, despite ensuing decades marked by seasonal flu vaccine safety.

"The 2009 H1N1 vaccine is essentially the same as any other seasonal flu vaccine," Toner emphasizes. "It changes every year and this was just another annual change in the vaccine. It was the same production method. There was never a reason to think it was going to be any less safe than it always is. That was primarily a communication failure."

What is somewhat lost in all of this is that a safe and effective pandemic vaccine was actually produced and widely distributed, notes Neil Fishman, MD, director of the department of Healthcare Epidemiology and Infection Control at the University of Pennsylvania Health System in Philadelphia.

"Certainly, there were a lot of issues with vaccine availability, but you know — darn it — there was always the question, 'Would we be able to manufacture a pandemic vaccine?' I think it's important not to lose sight of the fact that we did," he says. "We did it. The industry should be congratulated on that."

Mandatory HCW vaccine is on table

Now that the public has been reassured about safety and the production and distribution networks have been established, mandatory vaccine for health care workers is firmly on the table.

"I'll be very frank in saying that there has been an evolution in my thoughts on this" Fishman says. "I always thought that if you make the case and present the evidence, people will do the right thing. And it just hasn't happened. So, at the University of Pennsylvania, we made immunization with seasonal vaccine mandatory. We didn't push H1N1 because we didn't have enough vaccine early on."

After years of struggling, educating, and even producing music videos on the benefits of flu shots, "the best we were able to do was creep above a 50% vaccination rate. Now with our mandatory policy — out of nearly 15,000 employees — we only ended up with three that didn't get vaccinated. It took a lot of work and we worked with unions when necessary. We did a lot of education, we worked with religious leaders in the hospital and in the community. I really think it's the right thing to do and I hope that there is more of a push for mandatory vaccination," he reports.

The current president of the Society for Healthcare Epidemiology of America, Fishman says SHEA and the Infectious Disease Society of America are co-authoring an "evidence-based" statement favoring mandatory vaccination that could push the issue forward. The Association for Professionals in Infection Control and Epidemiology is on record as favoring mandatory seasonal flu vaccination of health care workers to end a longstanding threat to patient safety.


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