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If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”
Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.
Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?
Dismal Rates of Coverage
The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.
In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)
“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”
There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”
Underestimating the Disease
Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.
“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”
Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”
Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.
Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.
“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”
Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”
Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”
A Matter of Patient Safety
Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”
However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”
“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”
The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.
The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.
In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”
But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”
That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.
Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”
Bottom Line: Get Vaccinated!
How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)
Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”
Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”
Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.
AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”
Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”
Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”
The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”
It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”
If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”
Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.
Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?
Dismal Rates of Coverage
The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.
In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)
“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”
There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”
Underestimating the Disease
Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.
“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”
Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”
Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.
Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.
“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”
Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”
Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”
A Matter of Patient Safety
Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”
However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”
“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”
The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.
The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.
In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”
But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”
That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.
Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”
Bottom Line: Get Vaccinated!
How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)
Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”
Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”
Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.
AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”
Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”
Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”
The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”
It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”
If the golden rule of medicine is “First, do no harm,” some experts in infectious diseases think the majority of clinicians are dropping the ball—at least when it comes to influenza vaccination. For years, the rate of vaccination against flu among health care personnel has been “unacceptably low,” in the words of Neil Fishman, MD, President of the Society for Healthcare Epidemiology of America (SHEA), “despite Herculean efforts to increase it.”
Now, SHEA and other professional medical organizations think it may be time to take the gloves off (figuratively, of course). The organization recently published a position paper in Infection Control and Hospital Epidemiology in which it “endorses a policy in which annual influenza vaccination is a condition of both initial and continued [health care personnel] employment and/or professional privileges.” The recommendation applies to all health care providers (and other workers) in all settings, as well as students and volunteers.
Within two weeks of that paper’s release, the American Academy of Pediatrics (AAP) published its own policy statement recommending “implementation of a mandatory influenza immunization policy for all health care personnel.” Is this the way the wind is blowing—and how long and how fiercely will it blow?
Dismal Rates of Coverage
The call for mandatory influenza vaccination for health care providers may puzzle those who wonder how extensive the problem actually is. But surveys have shown that rates of flu vaccination among health care workers consistently hover at or below 50%: According to the National Health Interview Survey, rates did not improve significantly between the 2003-2004 and 2007-2008 influenza seasons (44.8% and 49.0%, respectively). A 2009 analysis by the RAND Corporation found that just 53% of surveyed health care workers reported receiving the vaccine during the previous flu season.
In January of this year, the CDC did announce that an estimated 62% of health care personnel had received the seasonal influenza vaccine during the 2009-2010 season—perhaps (pure speculation) because even those suspicious of the 2009 H1N1 vaccine felt the need for some layer of protection from flu and related illnesses. By comparison, the rate of coverage for the H1N1 vaccine was just 37% among health care workers, and only 35% reported receiving both vaccines. (Recall that health care providers were given priority status for the H1N1 vaccine, due to the nature of their work and greater potential for exposure to the virus.)
“One of the questions I’m frequently asked is, ‘What’s the rate among doctors? What’s the rate among nurses?’” says Gregory A. Poland, MD, who was one of two liaisons from the Infectious Diseases Society of America (IDSA) on the writing committee for the SHEA position paper, which has been endorsed by IDSA. “No one knows, nationally. We know that when we look at all health care workers in the US, the majority doesn’t get seasonal influenza vaccine. Between 50% and 60% of them don’t get it.”
There are bright spots; for example, in 2008, the American Academy of Physician Assistants (AAPA) included a question about flu vaccine coverage on one of its surveys. “I’m happy to say [the rate] was higher than I expected,” reports AAPA President Patrick Killeen, MS, PA-C. “Where the general population was at around 39% or 40%, among the PA population, 67% said they had received their flu vaccine.”
Underestimating the Disease
Overall, the available data suggest that most health care providers tend not to receive their annual influenza vaccination—which begs the question, why not? Some of it may have to do with a sense of invincibility; health care providers may see themselves as younger and healthier than other people—and therefore, less likely to become ill.
“Sometimes, it’s framed as altruism: ‘I’ll save the vaccine for my patients,’” Poland says. “But more often, it’s [because] they don’t understand that they need it and/or they’re afraid of side effects.”
Killeen points out that most people who do not get vaccinated against influenza cite safety issues or fear of getting the flu from the vaccine as their reason—and that includes health care workers, who should be better informed. “It’s concerning, because we perpetuate that miseducation, not only for ourselves,” he says. “That belief system is then passed on to our patients.”
Another issue may be the perceptions people have about flu versus those they have about vaccines. Although a causal relationship has never been established, there was an increase in cases of Guillain-Barré syndrome, and 25 deaths, during a government program to immunize people against swine flu in the 1970s. Whether the cause was the vaccine or the influenza itself, and whether people were directly affected, “that memory doesn’t go away,” as Killeen says.
Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.
“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”
Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”
Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”
A Matter of Patient Safety
Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”
However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”
“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”
The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.
The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.
In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”
But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”
That’s why the organizations have resorted to what some may see as a hard line on the subject (SHEA recommends that only medical contraindications should be acceptable exemption criteria; AAP, on the other hand, recommends that exemptions for medical and religious reasons be permitted on an individual basis). Fishman points out that vaccine mandates aren’t even unprecedented: Most institutions require vaccination against measles-mumps-rubella, varicella, and hepatitis B, for example, as a condition of employment.
Other arguments aside, Fishman says, there is one compelling reason why health care providers should get their annual flu vaccination. “Health care providers assume an ethical responsibility to prevent disease in our patients when we enter the profession,” he says. “That ethical obligation overrides other beliefs.”
Bottom Line: Get Vaccinated!
How far the push for mandatory influenza vaccination of health care personnel will go remains to be seen, as does what impact the movement will have on NPs and PAs. For the foreseeable future, it may depend on the practice setting. As of now, neither AAPA nor the American Academy of Nurse Practitioners (AANP) has taken a position on the mandate issue. (The American Nurses Association has, stating in a press release that it “does not support such policies” unless they adhere to specific guidelines. The organization does emphasize that it strongly encourages nurses to be vaccinated against influenza, however.)
Could this someday become a regulatory issue or a national health policy? “Initially, I’d be happy—we’d be happy—if more institutions around the country begin to adopt mandatory vaccination policies,” Fishman says. “If that happens, that will create a force around the country, and it will become the standard. If that doesn’t happen, I think we’ll have to see about pursuing more of a regulatory standard.”
Poland is a believer in the idea of a tipping point, and he thinks it’s drawing nearer: “I truly believe that within a decade, we will look back and say, ‘It is really unconscionable that we allowed this to happen,’ given the data that we have.”
Whatever else is accomplished in the immediate aftermath of the release of the SHEA and AAP papers, one thing is clear: It will hopefully encourage discussion about flu vaccine among health care providers, and perhaps encourage many of them to seek vaccination of their own volition. That is something both AAPA and AANP encourage. And perhaps too it will create opportunities for education.
AANP Director of Health Policy Jan Towers, PhD, NP-C, CRNP, FAANP, says that hospitals, clinics, and group practices can provide more education to their employees, showing data to indicate that not getting vaccinated is causing a problem. “Most people are conscientious providers,” she says, “and even though they may never get the flu—or they think they’ll never get it—if they are creating an environment that makes it easier for patients to get it, then showing that data and educating them would certainly be the way to go.”
Towers encourages NPs to receive flu vaccine—and to encourage their patients to get it as well (barring contraindications, of course). “One of the things that I think NPs do better than some other providers is make sure that people are getting their flu shots and that the vaccine is available to them,” she says. “I think that’s important. If you don’t bring it up with some of your patients, they’ll never think to get it. So we have a big responsibility to make sure our patients are aware of the need to get flu vaccine.”
Killeen has a twofold mission for his colleagues. “We really need to challenge our Ob-Gyn practitioners to vaccinate pregnant women,” he says. “Out of all the populations that I see, the one that refuses the vaccine is that population. Again, it’s the safety issues: ‘How will this affect my pregnancy and my unborn child?’ That’s a huge stretch for women.”
The second piece of Killeen’s request to PAs is not to rest on the laurels, so to speak, of that 67% coverage rate reported in 2008: “I would like to see that number significantly increase.”
It is important to remember that the entire concept of vaccination is that it protects you and helps to protect everyone else as well. “[The SHEA position paper] is saying that as a health care provider, you’re responsible to protect yourself and your patients,” Killeen says. “I think that’s the best thing to come out of it.”