New urgency added to annual flu campaigns

Will health care worker compliance improve?

Influenza had a major impact on the nation’s hospitals this season, filling up intensive care units and leading to staff shortages. The hardship caused by influenza has added vigor to campaigns to improve vaccination of health care workers.

About a third of hospitals faced a staffing shortage due to influenza, according to a study by the Centers for Disease Control and Prevention (CDC). The western region was the hardest hit, with 47% of facilities reporting staffing shortages due to influenza. That occurred despite an improvement in influenza vaccinations. Hospitals reported they had vaccinated 53% of their employees, an improvement over the previous rate of 44.5% for those hospitals. The 2000 National Health Interview Survey found that overall only about 38% of the nation’s health care workers receive the flu vaccine.

"Influenza takes out a portion of their work force right at a time when they’re particularly needed, because there’s also a surge in admissions," says William Schaffner, MD, chair of the department of preventive medicine at Vanderbilt University in Nashville, TN.

Schaffner also is on the board of the National Foundation for Infectious Diseases, which has placed a priority on improving immunization of health care workers.

The CDC also is placing a focus on immunization of health care workers. The agency is conducting focus groups with physicians and a national survey of nurses to try to understand why health care workers don’t get the vaccine.

The answers are likely to be varied, says Ray Strikas, MD, medical epidemiologist with the National Immunization Program. Past surveys have found that some health care workers believe the flu shot is ineffective, or even believe that you can get influenza from the vaccine. "There’s no one thing that is the issue. There’s no one thing that is the solution," he says.

Could JCAHO target flu vaccine?

Strikas and others have begun to question whether the Joint Commission on Accreditation of Healthcare Organizations could play a greater role in raising immunization levels. Currently, there is no standard that requires immunization of health care workers, but the Joint Commission requires hospitals to be in compliance with applicable laws and regulations.

"Nothing gets [hospitals’] attention more than questions by the Joint Commission and a need to demonstrate that they’re doing something vigorous," Schaffner points out.

Whatever the Joint Commission does, it won’t be related to a standard. "Our standards don’t specifically address [immunization of health care workers]," says JCAHO spokesman Mark Forstneger. But he adds, "If the organization’s own policies and procedures call for immunization, we would look at their compliance with that."

The CDC survey of hospitals found a wide range of immunization rates — from 12% to 100% of employees. Vaccination of health care workers rose nationally in the early 1990s, but has been stable for about seven years, according to National Health Interview Survey data.

"There are already things we know that work," Strikas says. "You can get vaccination levels of 70% or better in health care facilities."

The National Foundation for Infectious Diseases is working with numerous professional organizations in an effort to reach health care workers directly with the message that they need the annual shot to protect their vulnerable patients from hospital-based outbreaks.

"We want the organizations to promote health care worker vaccination on a regular basis to their own members," Schaffner adds.

"We want to turn it into expected behavior. We want to really change the culture," he notes.

The calls for improved immunization come during a season that was moderately severe, in which severe disease lead to 121 children’s deaths. And although avian influenza has faded from the front pages of the nation’s newspapers, it remains a great concern for CDC and world health authorities.

"We think it’s still really quite serious what’s going on in Asia," Scott Harper, MD, MPH, acting deputy section chief in the influenza branch told the Healthcare Infection Control Practices Advisory Committee (HICPAC). "This sort of geographic spread is really unprecedented."

Harper noted that some countries have begun repopulating their poultry markets, although the avian influenza virus still may be present.

"It looks like avian influenza is now embedded over a substantial geographic area in Asia," says Schaffner. "Instead of coming and going, it’s here to stay. The threat of viral recombination, such that the avian flu might pick up some genes that could spread in the human population, will be with us constantly rather than occasionally."

A vaccine against the H5N1 virus could be in clinical trials by this summer, says Strikas. "We don’t have a vaccine right now that we can put into people and prevent H5 disease," he adds. "We hope we would have H5 virus candidates in near term."

About three-quarters of hospitals implemented respiratory hygiene programs, with visual alerts and masks for patients and health care workers, according to the CDC survey of hospitals.