Vaccinating HCWs: essential preparation for influenza season

September 2004

The CDC recommends all health care workers (HCWs) receive an influenza vaccine every year, yet fewer than four in 10 do (Figure). While we monitor our patients’ immunization status and recommend vaccines based on CDC guidelines, it is clear that most HCWs do not follow these recommendations. By remaining unvaccinated, anyone who comes in contact with patients becomes a potential vector for influenza transmission to them. This is troubling for all patients, but particularly for those at high risk of influenza-related complications, including death.

We encounter high-risk patients throughout the influenza season in medical practices, general hospitals, specialty hospitals, long-term care and rehabilitation facilities, home care and other health care settings. Institutional outbreaks affecting a variety of patient types have been documented, including outbreaks in the elderly in a long-term care facility, neonates in an intensive care unit and patients in a transplant unit.

In each of these outbreaks, the HCW immunization rate was low. In the long-term care facility, where it was 10%, 65 residents developed influenza, and over one-half of those developed pneumonia. Nineteen were hospitalized and two died. In the neonatal intensive care outbreak, where only 15% of the staff was immunized, 19 infants were infected and one died. In the organ transplant unit, three of four patients with influenza had no visitors to account for the spread, leading investigators to conclude HCWs were the likely source of transmission.

Unvaccinated HCWs clearly can introduce influenza into a facility or propagate an outbreak, but who are “health care workers”? Medical professionals are not the only ones who come into contact with patients. An extraordinary spectrum of people works in health care institutions for the benefit of our patients. This includes physicians, nurses, physician’s assistants, pharmacists and therapists of all kinds. But it also includes social workers, psychologists, paraprofessionals, security personnel, the entire cadre of service employees who work with us in our clinics and larger institutions, volunteers and students of various medical disciplines. All are potential vectors who can transmit influenza virus to our patients.

NFID initiative, others

Source: CDC. MMWR. 2003; 52(RR-8):1-36.

The National Foundation for Infectious Diseases (NFID) sponsored a recent daylong roundtable of experts from many disciplines. The impact of low influenza immunization rates in HCWs was discussed at length. The findings were published in two documents, both of which are available on the NFID Web site at www.nfid.org/publications.

The “Call to Action,” supported by all 25 organizations that attended the roundtable, calls for “a comprehensive, concerted effort by health care institutions, employers, insurers and allied professional organizations ... to improve health care worker influenza vaccination rates.”

The NFID also issued a comprehensive report, “Improving Influenza Vaccination Rates in Health Care Workers: Strategies to Increase Protection for Workers and Patients,” stressing the importance of annual influenza vaccination of HCWs and urging institutions to facilitate annual employee influenza immunization programs.

Others groups have taken up the cause. The Association for Professionals in Infection Control (APIC) has provided all of its members with a policy statement advocating widespread influenza vaccination of HCWs. APIC surveyed its members about HCW influenza vaccination practices and highlighted this topic at its 2004 annual meeting. The National Influenza Summit, organized by the CDC and the American Medical Association (AMA) and representing more than 90 of the nation’s leading health care organizations committed to influenza immunization, has encouraged its members to share the NFID “Call to Action” and report with their constituents. And, the AMA has highlighted the NFID’s initiative in its Federation News, which reaches more than 100 of the AMA’s network of state, regional and county medical societies.

Further, the CDC’s Healthcare Infection Control Practices Advisory Committee is working with the Advisory Committee on Immunization Practices to develop a joint policy statement for publication in the Morbidity and Mortality Weekly Report.

Institutional call to action

Because HCW immunization is an important patient safety and infection control issue, all health care facilities should commit necessary resources to increasing immunization rates among all employees. Institutions should provide an immunization program that makes vaccination convenient and low cost, or even better, free of charge.

The NFID report reviews specific strategies and interventions used successfully by facilities across the country to increase HCW vaccination rates:

• Making one person or department directly responsible for developing and managing the employee vaccine program
• Securing commitment to employee influenza vaccination from top management
• Developing a policy statement affirming the institution’s commitment
• Delivering positive messages to employees using all means possible
• Making influenza vaccine easily accessible to personnel on all shifts, including those who work only weekends or part time
• Removing cost barriers for employees
• Monitoring the program’s successes and failures and using this knowledge as the program is adjusted and implemented every year

While every health care institution needs to act to protect its patients, so must the individual HCW. Our primary message to these workers is one that medical professionals have heard many times: “First, do no harm.” All HCWs need to hear that one of the major reasons we would like them to get vaccinated is so they do not make healthy patients sick or their sick patients even sicker.

Another very important message is, “We need you during the influenza season.” We need our HCWs to be healthy and on the job, especially during influenza season. What we do professionally is care for the sick; it is our duty to maintain our own health so we can do our jobs when there is influenza in our communities.

There is also the personal message for HCWs: “Protect yourself and your family.” Many HCWs are at high risk, some because of underlying medical conditions, but many because they are age 50 or older — thus, in a group in which annual influenza vaccination is recommended regardless of other risk factors. HCWs must consider their families. Our work environment puts us face to face with respiratory pathogens such as influenza. Immunization lowers our risk of becoming infected and transmitting illnesses to our spouses, children, grandchildren, elderly relatives and others.

No one can predict how any upcoming influenza season will unfold, so it is essential we prepare every year as if “the worst” were on the way. The best way to prepare is through widespread influenza vaccination, including HCWs. Much was written last year about the incomplete match between the circulating strains and those chosen to be included in the vaccine. Nevertheless, reports now indicate the vaccine was 40% to 60% effective, even in young children. In most years, the antigenic match is better and the vaccine is even more effective.

In an “average” year, influenza kills an estimated 36,000 Americans and is responsible for well in excess of 100,000 hospitalizations. Vaccination is our primary means of defense. As health care providers and employers, it is our responsibility to follow the same advice we give our patients: get your vaccine! It is the professional thing to do.

For more information:

• National Foundation for Infectious Diseases. “Improving Influenza Vaccination Rates in Health Care Workers: Strategies to Increase Protection for Workers and Patients.” 2004. Washington. Available at www.nfid.org.

• William Schaffner, MD, is chair of the department of preventative medicine at Vanderbilt University Medical Center and a member of the board of directors of the National Foundation for Infectious Diseases.