Call to action: Flu shots for HCWs becoming a patient safety issue

Myths, misconceptions leave 62% not immunized

Spurred by historically poor flu immunization compliance in an age of patient safety, some powerful health care forces are converging to make the annual flu shot a new professional standard for health care workers.

"We are really trying to change the culture," says William Schaffner, MD, chairman of the department of preventive medicine at Vanderbilt University Medical Center in Nashville, TN. "We would really like to inculcate the notion that it is a professional standard to get influenza vaccine each autumn if you are a health care worker. Not only nurses and doctors, but literally everyone who works in a hospital, a nursing home, a freestanding surgical facility — you name it. We’re trying to make the health care environment an influenza-free zone."

Schaffner is one of the lead authors of a recent report on the issue by the National Foundation for Infectious Diseases (NFID), which has rallied an impressive group of partners that include the Centers for Disease Control and Prevention (CDC), and the Joint Commission on Accreditation of Healthcare Organizations.1 However, the Joint Commission — which many see as a key player in the success or failure of the campaign — is expressing both interest and caution on the issue. Specifically, there is some question whether there are sufficient data to support the notion that widespread immunization of health care workers of every stripe would really yield patient safety benefits, says Robert Wise, MD, vice president for standards at the Joint Commission.

"We are interested in getting behind the idea that health care workers in high-risk situations should be immunized for flu," he tells Hospital Infection Control.

"The issue is trying to understand what those high-risk situations are. That’s where the rubber meets the road and the research has to be done. We are specifically looking into making a recommendation on this subject, but until we get more research and more input, we’re not sure how broad that recommendation is going to be. Our position is to do this as a patient safety issue — not an employee health issue," Wise says.

HICPAC, ACIP to issue joint endorsement 

Meanwhile, two of the CDC’s major advisory committees are developing a joint statement that is expected to urge action on the flu vaccination issue. The CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Council on Immunization Practices (ACIP) are expected to issue the joint statement in an upcoming issue of the Morbidity and Mortality Weekly Report.

"Both ACIP and HICPAC consider this an important thing," says Jane Siegel, MD, who has served on both committees and also participated in the NFID report. "Patient safety is one of the issues. Also, when health care workers have influenza and are absent, that affects staffing ratios. Having inappropriate staffing has been associated with adverse outcomes."

Indeed, the NFID report cites studies that show using pool staff in place of experienced unit staff increases adverse events in patients. Flu-related absenteeism also may force staff to work double shifts, degrading the quality of care. In the current nursing shortage, however, it’s just as likely that sick nurses will feel bound to show up at work, Wise adds.

"The pressure right now for people to go to work because of the shortages makes it more likely that a sick person may show up," he says. "We actually have a situation where someone who is sick is less likely to isolate themselves during their infectious period."

If so, influenza can be transmitted directly from health care workers to their immune-compromised patients. For example, in 2001, four documented influenza cases occurred within four days in a 12-bed, single-room transplant unit.2

Three of the four infected patients had no visitors between admission and influenza infection to account for the spread, leading investigators to conclude unvaccinated health care workers were the likely source of transmission. Three nurses among the 27 health care workers in the unit also developed influenza.

"The literature on this is not as extensive as you would think," Schaffner says. "That’s because these are hard studies to do — to document explicitly that individuals transmitted flu to their patients. There have been a few studies; but when you talk to people, the anecdotes just come jumping out at you. There is no question that it is happening."

ICPs should take the lead 

When influenza infects patients, results can be severe. An increase in mortality generally accompanies influenza epidemics, not only from respiratory illness including pneumonia, but also from exacerbation of pre-existing conditions such as heart, lung, and kidney diseases, and bacterial superinfections, the NFID report states. One reason health care workers transmit influenza is they often continue to work while infected with the virus. Another reason is poor adherence to infection control practices, such as isolation recommendations (droplet precautions) and hand hygiene.

"Really, ICPs should be taking the lead on this issue," says Tammy Lundstrom, MD, a member of NFID panel that composed the report. "The role of an ICP is not just to prevent patient-to-patient transmission but prevent health care worker-to-patient transmission. I really think that ICPs can and should play a major role."

Historically, the vaccine has been presented as a personal choice for employees, but in today’s climate of patient safety, that emphasis seems increasingly inappropriate and ineffective.

"It always has been a patient safety issue but it hasn’t been promoted that way," Lundstrom adds.

"It has been promoted in the past as an individual choice rather than as a patient safety thing. We may have more success promoting it as patient safety initiative than we do as an individual choice because most health care workers would go out of their way to prevent something untoward from happening to patients," she notes.

So given the obvious benefits, why do only some 36% of health care workers get the annual flu shot? At least part of the answer is mired in myths and misconceptions that go back decades.

"We still have the barrier of individuals believing that they can get influenza from the killed influenza vaccine," Lundstrom says.

"We still have individuals thinking that they are not at risk. They have never had the flu, so they [believe they] will never get the flu. If you look at the literature, it shows that people who either had the flu or have been vaccinated once are more likely to be vaccinated again. We really have to work on busting these myths about influenza vaccination," she adds.

One reason behind the myth that a killed vaccine could transmit a live virus may go to back decades ago when the flu vaccine was less purified than the current versions, Schaffner says.

Febrile reactions and soreness were more common, but that wasn’t the flu. "The reputation for flu vaccine was started 30 years ago, when the flu vaccine was not nearly as purified, and it was then common for people to not only get a sore arm but a day or two of fever," he says. "Then people would say I got flu from the flu vaccine.’ You don’t get flu from the flu vaccine, but this myth regarding flu vaccine is alive and well in some groups of health care workers; and I hesitate to say this, but especially nurses. We didn’t think we had to address that with health care workers, but clearly we do."

The message can be somewhat complicated, because there have been cases of infection in those already incubating flu when they received their vaccination. The resulting infection could cause the perception that either the vaccine was ineffective or actually caused the flu. "You need at least a couple of weeks after vaccination before you are fully protected," Lundstrom says. "So besides saying you are not going to get the flu from the flu vaccine, we have to tell people the other reasons why they still might get the flu despite taking the flu vaccine. And emphasize that if you do get the flu after vaccination, then generally you will have a milder illness than you would if you had not been vaccinated."

Though patient safety has become something of a medical buzzword, many health care workers still view the flu shot as a personal health issue.

"As I went through this process, I had always assumed that health care workers were a reasonably sophisticated group and understood that the reason that they were being asked to be immunized was to protect patients," Schaffner says. "We discovered that this [rationale] is not well known among health care workers. It is not well known, for example, that after you have been infected with the influenza virus — but before you get sick — you can actually transmit the virus to your patients. We haven’t been clear in giving health care workers that message."

According to the NFID report, an individual generally is infectious about one day before and five days after symptom onset. Approximately 30% to 50% of infected people may remain asymptomatic, but they can still transmit the virus to others. That means a nonvaccinated worker who feels relatively fine may transmit the virus to sick and compromised patients with potentially deadly results.

Could regulation result?

Given that possibility, some are suggesting stronger measures, such as adding an accountability factor by having workers sign declination forms if they refuse a vaccine offer. In addition, there are rumblings of a more regulatory approach, mandating the vaccinations rather than leaving it to voluntary compliance. The latter is much preferred by health care officials, but as the problem gets more attention, calls for regulation may increase if immunization rates don’t.

"It’s not like certain one-time immunizations that can be given at hire," Schaffner says. "Flu is annual, and nobody wants to struggle with anything that is regulatory on an annual basis. However, we would like various hospital and health care regulatory agencies to inquire about it. We would love to see the Joint Commission come into hospitals and add to their question list one or two on influenza immunization rates. Show me your data. How are you doing?’ I think that would stimulate the institutions to more vigorous action."

Indeed, one of the keys to improving the situation is getting top hospital administrators on board. "Obviously, since we see this as a patient safety issue; it is an institutional responsibility," he says. "We need pictures in our medical center newsletters of the senior members of the administration getting vaccinated. You have to let the middle managers know that the influenza vaccination rate of the personnel in their unit is going to be noted and will be commented on, for better or for worse. We would like to see 90% of health care workers vaccinated ever year. Just as a matter of course — year in and year out."


1. National Foundation for Infectious Diseases. Improving Influenza Vaccination Rates in Health Care Workers: Strategies to Increase Protection for Workers and Patients. Web:

2. Malavaud S, Malavaud B, Sander K, et al. Nosocomial outbreak of influenza virus A in a neonatal intensive care unit. Infect control Hosp Epidemiol 2000; 21(7):449-451.