A reason to vaccinate: Flu led to staff shortages

CDC studies HCW vaccination

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 that 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.

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 says.

Whatever the Joint Commission does, it won’t be related to a standard. "Our standards don’t specifically address [immunization of health care workers]," explains 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," says Strikas. "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 in order 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."

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." He noted that some countries have begun repopulating their poultry markets, although the avian influenza virus may still 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, Strikas notes. "We don’t have a vaccine right now that we can put into people and prevent H5 disease. 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.

In a move to give an option to health care workers wary of needles, the Healthcare Infection Control Practices Advisory Committee agreed with a recommendation that the live attenuated influenza virus (LAIV) vaccine, which is administered intranasally, could be used with health care workers. The vaccine is marketed as FluMist and was available this year for healthy people ages 5 to 49.

Now, two CDC advisory panels have stated that the traditional, inactivated influenza vaccine is preferred only when health care workers have close contact with "severely immunosuppressed persons" such as those undergoing hemotapoietic stem cell transplants. Close contact with patients with "lesser degrees of immunosuppression," including HIV, would not prevent health care workers from receiving the LAIV vaccine.

If health care workers receive the LAIV, they should refrain from close contact with severely immunosuppressed patients for seven days, the panels decided. In the past flu season, high demand led to a shortage of the inactivated vaccine, but about 4 million doses of FluMist were unused and ultimately destroyed.