As influenza vaccine supply increases, now is the time to encourage HCW vaccination

October 2005

As of this time (Sept. 20, 2005), the supply of inactivated trivalent influenza vaccine for the coming year seems pretty well assured.

Sanofi-Pasteur has been on track to deliver its customary 55 million doses. GlaxoSmithKline, having received FDA approval for its vaccine several months ago, is expected to provide about 10 million doses. Chiron passed its Good Manufacturing Practices inspection during the summer, and just last week received FDA approval to distribute their vaccine; about 18 million doses are anticipated. In addition, MedImmune will be able to supply between 3 to 4 million doses of live-attenuated influenza vaccine (LAIV, FluMist) for use in healthy people aged 5 to 49. This should return the U.S. vaccine supply to its supply level before Wyeth-Lederle stopped making inactivated influenza vaccine and before last year’s Chiron debacle.

Nonetheless, the distribution schedule is still unclear, and so the CDC is still recommending a “tiered” immunization schedule, in which only priority groups would receive vaccine prior to Oct. 24, 2005. The priority groups, as noted in the Sept. 16th issue of the Morbidity and Mortality Weekly Report (MMWR), are as follows:

• People aged >65 with comorbid conditions
• Residents of long-term care facilities
• People aged 2 to 64 with comorbid conditions
• People aged >65 without comorbid conditions
• Children aged 6 to 23 months
• Pregnant women
• Health care personnel who provide direct patient care
• Household contacts and out-of-home caregivers of children aged <6 months

Perhaps, we should not yet be totally reassured about vaccine supply; recall that it was about this time last year that we first heard about Chiron’s problems. At this time, however, supply appears to be on track.

Beginning about two years ago, the National Foundation for Infectious Diseases (NFID) and the CDC jointly have sponsored an initiative to bring about improved influenza vaccination of health care personnel. We have for years been seemingly content with poor coverage levels of 35% to 40% or even less, and only rarely more than 50%.

80% coverage

The goal of the CDC/NFID initiative is to bring about coverage levels of 80% or better among health care workers that provide direct patient care. This initiative is based on the well-documented observations that physicians and nurses transmit influenza to their patients, and that even asymptomatic people are fully capable of transmitting influenza to others. Therefore, as health care workers, we have an obligation to be vaccinated, not so much to protect ourselves, but to protect our patients. It is, very simply, a patient safety issue.

This initiative has never reached its full potential, largely because the last two years have been seasons of vaccine shortage or significant mismatch, and it is difficult to sell the idea of vaccination to healthy physicians and nurses, when the news media are full of headlines about vaccine shortages.

This year, with the anticipated good supply of influenza vaccine, it is high time to make a major effort to immunize all health care workers that provide patient care, even though these workers may be healthy. Eighty percent or better is an achievable goal, but it will take planning and effort. Simply making vaccine available will no longer suffice! We, the vaccinators, can’t depend on health care workers to come to us; we must go to them – every nursing unit and every shift. This requires support from the highest levels of hospital administration, and there is no better publicity than a hospital’s chief executive officer being first in line for his or her influenza vaccine.

Mandates?

Earlier this year, Dr. Greg Poland, director of the Mayo Vaccine Research Group, and several colleagues published a paper arguing for the health care community to take the next step, that is, requiring influenza vaccination for health care workers. (Vaccine. 2005;23:2251-2255.) After a brief introduction, the authors outlined seven points (“truths”), all established facts that buttress the argument that influenza vaccine should be mandated for health care workers. These are as follows:

• Influenza causes serious morbidity and mortality, and adversely affects public health every year.
• Influenza-infected health care workers can transmit this virus to their vulnerable patients.
• Influenza immunization of health care workers saves money for both employees and employers, and prevents workplace disruption.
• Influenza vaccination of health care workers is already recommended by the CDC, and is, in fact, the standard of care.
• Immunization requirements are effective and increase vaccination rates.
• Health care workers and health care organizations have an ethical and moral duty to protect their patients from transmissible diseases.
• Finally, the health care system must either lead, or be harshly judged by, society.

The argument is sound, and the scientific rationale is unassailable. To bring this about will require strong support from a number of organizations, including the NFID, the CDC, the Association for Professionals in Infection Control and Epidemiology, the Society for Healthcare Epidemiology of America, as well as the IDSA, the American College of Physicians, the American Academy of Family Physicians and the American Medical Association. It may eventually happen – and I hope it does – but it will require a lot of selling from the American Hospital Association and other similar organizations.

Meanwhile, it didn’t take long at all for the opposition to surface. The American College of Occupational and Environmental Medicine, in a new statement on influenza control for health care workers, has taken the position that mandatory influenza vaccination of health care workers is not justified, because the organization doesn’t believe it works. Anticipate that many employee groups, such as the Service Union International, will provide further opposition. Much more will be heard about this issue in the months and years ahead.

What can we expect in the influenza season ahead? The Sept. 16 issue of MMWR contains a summary of influenza activity both globally and in the United States from May through early September. This information, especially that from the Southern Hemisphere, often provides a guide to what might be expected during the Northern Hemisphere winter. This year the guidance is occult; both influenza A (H3N2) and influenza B outbreaks have occurred, often in the same country. Worldwide, there has been little activity of influenza A (H1N1). No dramatically new strain of either influenza A or B has been recognized to date, although there has been evidence of continued slow antigenic drift of influenza A (H3N2).

After two consecutive years of predominant influenza A (H3N2) activity in the United Sates, perhaps, we will “catch a break” and have a relatively quiet year, or an influenza B year. Or neither.

Space does not permit discussion of avian influenza issues, but that will be discussed further – soon.