First do no harm? Health care workers imperil patients by snubbing flu shots

First do no harm? Health care workers imperil patients by snubbing flu shots

SHEA: Use declination forms to push flu vaccine

In cold fact, some unknown number of hospital patients and nursing home residents die of influenza — year in, year out — because they were treated by health care workers who declined flu vaccination.

Maybe the workers mistakenly thought the vaccine would give them the flu, a myth that persists like an urban legend despite the fact that the annual concoction uses killed flu virus. Maybe they work in a setting that refuses to remove logistical barriers of cost or inconvenience. Maybe no one has bothered to inform them of the clear epidemiological link between patient infections and treatment by unvaccinated health care workers. They may not know that they can transmit flu during the asymptomatic onset of influenza or during a mild infection that is little more than a nuisance to them. One study found that 28% of health care workers with serologically confirmed flu infections did not recall having a respiratory infection during the period.¹

The patient may not be so lucky. Already immune-deficient, he or she may die of a respiratory infection that may not even officially be diagnosed as influenza unless it occurs in the context of a nosocomial outbreak. The huge proportion of health care workers who defer flu vaccination each year in the United States — almost two-thirds of the total work force by some estimates — may not know all of the above. Yet many an infection control professional goes to bed at night knowing it all too well.

"Unvaccinated health care workers kill the people they take care of. It’s that simple," says Allison McGeer, MD, FRCPC, director of infection control at Mount Sinai Hospital in Toronto.

A succession of randomized clinical trials have shown the protective effect upon patients when health care workers are vaccinated against influenza, she says. "At the [European] influenza meeting in Malta this year, they presented a third randomized controlled trial of vaccinating health care workers," she says. "Exactly the same results as the first two — [a] 40% decrease in all causes of [patient] mortality."

In an age of patient safety, there is broad agreement that the status quo no longer is acceptable. "Health care worker influenza vaccine is not just a health care worker issue. It’s a patient safety issue. That message has been diluted or lost," says Thomas R. Talbot, MD, MPH, assistant professor of preventive medicine at Vanderbilt University Medical Center in Nashville, TN, and lead author of a new position paper on health care worker flu immunizations by the Society for Healthcare Epidemiology of America (SHEA).²

The SHEA paper reports that in two separate studies in geriatric long-term care facilities, total patient mortality was significantly lower in those sites where health care workers were vaccinated when compared to sites where routine vaccination was not offered to HCWs (10% vs. 17% and 14% vs. 22%).^{3, 4} Increased rates of HCW vaccination also correspond with a significant decrease in the incidence of health care-associated influenza.⁵

While SHEA did not go as far as recommending mandatory flu vaccinations for health care workers, others argue it is time for the "m" word to be brought into play. The authors of a recent paper advocating mandatory flu vaccinations for health care workers note that the current immunization apathy among clinicians would simply not be tolerated if the annual virus had a more exotic profile.⁶

"If we had a safe and effective vaccine against a newly emerging infection such as SARS or avian influenza, would we allow health care workers to care for infected patients without having received the vaccine?" they ask. "Conversely, would we allow infected health care workers to care for uninfected patients? In fact, concerns about the ethics of such behavior would surface almost immediately. Yet, we allow precisely these situations to occur with a virus that kills 36,000 Americans every year."

We’re not making the diagnosis’

While many nursing homes are getting the message, many hospital administrators remain unconvinced it’s a significant problem, McGeer says.

"We’re not making the diagnosis [in hospitals]," she explains. "We really only diagnosis it in nursing home outbreaks. When you don’t diagnose it, people don’t see it and they don’t recognize it. That has fostered this attitude that influenza doesn’t kill people. Until people see that influenza kills people, we are not going to make the progress we need to on this."

Concurring with McGeer, Talbot says the sense of complacency around flu vaccination stems in part from inadequate case surveillance in the nation’s hospitals.

"The difficulty of pushing forward health care worker influenza vaccination is that it is very hard to define the burden of nosocomial transmission of influenza," he says. "Unless you are really looking for it or you have a larger outbreak, you’re not going to really have a sense of that burden. We have a lot of accounts of bad outbreaks, but that is just the tip of the iceberg regarding the impact of nosocomial flu. We don’t recognize it because we don’t do the intensive surveillance to pick it up for every unexplained respiratory illness in our hospitalized patients."

The SHEA position paper recommends that facilities conduct routine surveillance for health care-associated influenza to assess the impact of their worker vaccination program. The SHEA guidelines also address the difficult and ethical issue of allotting flu vaccine during the kind of shortage that occurred last season.

"The allocation guidelines are something that no one has tried to take a stab at, at least in health care workers," Talbot says. "We felt we needed to come to the forefront and provide out rationale as a society on how we would allocate and prioritize vaccinations for health care workers."

Of course, rather than scrambling for vaccine during a shortage, the typical flu season finds health care workers turning their back on an abundance. "There is still a very pervasive myth that [they] are going to get sick from the flu vaccine," Talbot says. "[We thought] surely people don’t think that anymore since we’ve gotten more data. It really does persist. Studies as recent as last flu season suggest that a substantial portion of people don’t want the flu vaccine because [they think] they are going to get sick."

While some trace this distrust to the swine flu debacle in the 1970s, Talbot says it is more likely a result of acquiring other respiratory infections after being immunized for flu. There is no shortage of circulating bugs during the winter months and an infection may be incubating when the worker receives the flu shot. As they become symptomatic, they may think they acquired flu from the vaccine. As a result, they vow never to take the shot again and reinforce the myth with their personal testimony to co-workers. Less elaborate disincentives also exist.

"Some institutions make them pay for it," says David Weber, MD, a co-author of the SHEA paper and director of epidemiology, occupational health, and environmental health and safety at University of North Carolina Hospitals in Chapel Hill. "It should be given free. Some tell them to go to their own doctors and get it done. Some say you have to make an appointment two weeks ahead of time or that [shots] are only available Friday at noon. There are logistical barriers that many institutions have in place."

While not advocating mandatory flu vaccination, SHEA takes the bold step of recommending that health care workers that decline flu immunization must sign a declination statement. Slated for publication in the November 2005 issue of Infection Control and Hospital Epidemiology, the position paper recommends that all health care workers be immunized for flu annually unless they have a contraindication to the vaccine or actively decline vaccination. Similar recommendations are under discussion at the Centers for Disease Control and Prevention.

Declination statements

Though it’s a controversial recommendation, declination statements not only speak to personal accountability, but attest that education has been delivered about the need for the vaccine. The same tact has been used to reduce occupational hepatitis B virus infections, which fell sharply after HBV declination statements and other infection control measures were required by the Occupational Safety and Health Administration.

"From the data that we have on hep B vaccination rates and the incidence of nosocomial and health care worker transmission of HBV, the percentage of adherence to the vaccination has climbed markedly and the numbers of cases of contracted hep B have declined markedly," Talbot says. "While there are other things that also happened — such as implementation of standard precautions — I think indirectly and fairly strongly the evidence suggests that active declination is a part of it."

Still, SHEA emphasizes that the declination statement must be used as part of a multifaceted targeted campaign addressing a variety of issues. "We [stress] that facilities do all of the other components — make it convenient, pay for it, educate about the myths about the vaccine," Talbot says. "But we still have trouble with our adherence rates. It’s such a vital issue, we really felt we had to put a little more teeth behind it."

SHEA acknowledges that adopting its declination statement recommendation will require resources and support for the infection control and employee health programs that will have to implement it. "Our colleagues in occupational medicine will bear the brunt of that, and they are traditionally less funded than the infection control teams are," Talbot says. "So it is really something that by mandating that it may actually help [raise] awareness from the top down and [increase resources]. We really want to bring it to the forefront because there is an increasing emphasis in measures that improve and ensure patient safety, and [flu vaccination] should be one of them."

Indeed, health care worker flu vaccination rates are appearing increasingly in quality measures disclosed on infection control report cards. As more states pass laws requiring infection rate disclosure, health care worker immunization rates may be open to public scrutiny.

"If you are going to mandate reporting something in the infection control arena, that is a very good process measure," Talbot says. "It almost takes these kinds of mandates to get the attention and direction of resources from administration."

However, Weber says declination statements should not be viewed as a panacea, noting ironically that he probably would require HBV vaccination at his facility if OSHA had not given workers an "out" through a declination statement.

"If OSHA hadn’t done that, we would actually have HBV vaccination required," Weber says. "You can say it’s helped, but it hurt me because we have a very aggressive program. I can’t legally make someone take the HBV shot. Unless you have a contraindication, our hospital policy is that you don’t have mumps, measles, rubella, varicella shots, you don’t work here. [OSHA] allowed them an out."

That said, Weber does not advocate mandatory flu shots and has doubts about whether declination statements will be workable in large hospitals like his.

"Declination statements are on the table," he says. "It’s a way of making sure your population is informed about the values and risks of not being vaccinated. This is one of many options that you have to improve coverage. I think that’s the way it should be looked at."

Why not mandate flu shots?

Still, given the patient safety risks, why not simply mandate flu vaccination as a condition of health care work?

"The problem with making flu shots mandatory is less one of philosophy than of one of practicality," he says. "I personally, believe that every employee should get their flu shot. I just think the flu shot is just logistically very difficult, the same thing with the mandatory declination."

For example, mandating one-time vaccinations is relatively simple, but flu vaccination requires new shots every year. Are hospitals really ready to cancel laser surgeries because they had to fire a technician that refused to get a flu shot, Weber wonders. Other issues include workers that work odd shifts, part time, on maternity leave, and the like.

"It would be so much easier if we got [the flu vaccine] in August instead of just coming out sort of in the nick of time," he says. "We have roughly 6,000 workers in our hospital and three nurses in infection control. If the flu shot is going to work, you need to start giving it Nov. 1, assuming we get vaccine. Suddenly, I am going get this big supply and have to give to it to everybody by Dec. 15, roughly. What I am going to do with the employee who is out on maternity leave or working once a month, or only weekends?"

Realistic concerns noted, Weber runs an aggressive immunization program that yields 80% flu immunization rates among the health care staff.

"We push hard and we do all the things we can," he says. "We give the vaccine free and have open walk-in hours. Certain times a day you can just walk in and get your shot without an appointment. We guarantee that if you walk in, you will have your shot in 10 minutes. We go out to the wards, medical grand rounds, nursing education meeting, board members. We let the nursing supervisors give shots to capture people at nights and weekends and so on."

In particular, the program targets health care workers of "highest concern," those in the emergency room, neonatal intensive care units and bone marrow transplant units.

"Those we do almost 100%," he says. "One of the reasons we have chosen not to go to mandatory [flu vaccinations] is because we are doing so good in those units anyway."

Reacting to demands for mandatory flu shots and declination statements, the American College of Occupational and Environmental Medicine (ACOEM) recently released a position statement that opposes both measures. The ACOEM opposed the use of declination statements because there is "no evidence to suggest that such programs will increase compliance."

Similarly, the college rejected mandatory flu shots because the vaccine itself is variably effective; vaccination does not preclude the need for other controls; and a coercive program has the potential to harm the employer-employee relationship.

In addition, the ACOEM pointed out that "given the ubiquitous nature of influenza in the community, patients will continue to be exposed to influenza through family members and friends regardless of the vaccination status of their health care workers, with whom they have much less intimate contact."

Weber concedes that declination statements can be problematic, but challenged the college on its assertion that mandatory shots erode employee-institution relationships.

"I think that [the ACOEM) is absolutely wrong that [required shots] harm the relationship with the employee," he said. "In fact, it’s the opposite. Most of our employees, the overwhelming majority, [appreciate] the fact that we make these shots mandatory and provide them free."

(Editor’s note: the SHEA position paper is available at: www.shea-online.org. The ACOEM position paper is available at www.acoem.org/guidelines/article.asp?ID=86.)

References

1. Elder AG, O’Donnell B, McCruden EA, et al. Incidence and recall of influenza in a cohort of Glasgow healthcare workers during the 1993-4 epidemic: Results of serum testing and questionnaire. BMJ 1996; 313:1,241-1,242.
2. Talbot TR, Bradley SF, Cosgrove SE, et al. SHEA Position Paper: Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages. Infect Control Hosp Epi 2005: In press.
3. Carman WF, Elder AG, Wallace LA, et al. Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: A randomised controlled trial. Lancet 2000; 355:93-97.
4. Potter J, Stott DJ, Roberts MA, et al. Influenza vaccination of health care workers in long-term-care hospitals reduces the mortality of elderly patients. J Infect Dis 1997; 175:1-6.
5. Salgado CD, Giannetta ET, Hayden FG, et al. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004; 25:923-928.
6. Poland GA, Tosha P, Jacobson RM. Requiring influenza vaccination for health care workers: Seven truths we must accept. Vaccine 2005; 23:2,251-2,255.