Hospital Infection Control

HCW Influenza vaccination programs

How do the contributions of HCP Influenza Vaccinations impact infection control currently, and how does the vaccination program interact with other aspects of infection control?

Influenza causes considerable yearly morbidity and mortality in the United States. Annually, approximately 36,000 deaths and over 200,000 hospitalizations are attributable to influenza infection. There is a higher risk of developing of influenza complications among children aged <2 years, persons aged ≥65 years, pregnant women and patients with underlying medical conditions. The virus may be transmissible from persons with subclinical infections, including healthcare personnel (HCP), exposing patients and these high-risk individuals to the virus before symptoms develop.

Control of influenza in healthcare settings requires a comprehensive influenza control plan which includes patient and staff vaccination, early recognition and prompt isolation of potential influenza cases, education for patients, visitors and staff about respiratory etiquette (e.g., cover your cough) and hand hygiene, and human resources policies that encourage employees not to work when ill. This chapter will focus on HCP influenza vaccination but the other elements are also crucial to influenza control.

Influenza infection is the principal cause of vaccine-preventable death in the United States every year and, while an improved vaccine with better and more durable protection is needed, the currently available vaccines are still the most effective method for preventing influenza infection and its complications. The current recommendations by the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) are that all HCP be vaccinated each influenza season.

According to the CDC, healthcare workers include, but are not limited to; “physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual staff not employed by the health-care facility, and persons (e.g., clerical, dietary, housekeeping, laundry, security, maintenance, administrative, billing, and volunteers) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from health care workers and patients.”

At present, the vaccination coverage of healthcare workers remains suboptimal. The 2014-2015 early season health care personnel vaccination coverage was 64.3%. The Healthy People 2020 target for percentage of healthcare workers who are vaccinated annually against seasonal influenza is greater than 90.0%. Although the percent of healthcare personnel who received the influenza vaccine is up 18.8% since 2008, it is clear that more needs to be done to ensure adequate levels of vaccination coverage.

There are several reasons that HCP influenza vaccination is important for patient protection. Vaccination of HCP has been shown to decrease morbidity and mortality among residents of long term care facilities in several studies. This impact can be harder to demonstrate in acute care settings where lengths of stay are shorter and where patients have been demonstrated to lack classic influenza symptoms making case discovery through routine care challenging. However several studies have also shown an association between increasing HCP influenza vaccination rates and decreasing incidence of nosocomial influenza infections in patients. In addition, HCP, like many other professions, frequently work while ill which can put patients at risk. Patients already in healthcare settings are usually at higher risk of complications from influenza.

What elements of HCP Influenza vaccination programs need to be need to be adhered to for prevention and control?

The most important goal for a HCP influenza vaccination program is high rates of vaccine uptake. The CDC’s Healthy People 2020 goals include a target influenza vaccination rate of over 90% for healthcare facilities. Routine influenza vaccination for healthcare workers is used as a quality metric and is reportable to the National Healthcare Care Safety Network (NHSN) at CDC. The Joint Commission for Hospital Accreditation requires facilities to set goals for improving healthcare worker influenza vaccination rates without defining a specific target. Furthermore, NHSN recommends that healthcare administrators should consider the level of HCP vaccination coverage to be a possible measure for inclusion in a patient safety quality program.

Methods to Improve HCP Vaccination Coverage

There are several key themes important to programs working to increase vaccination coverage. These themes include:

Prioritization: Routine Influenza Vaccination should be made an administrative priority in healthcare facilities, using tools such as a strong and visible administrative leadership with a transparent endorsement of vaccination and “train-the-trainer” programs and educational tools to inform employees about the benefits of vaccination and the associated risks of refusal.

Availability: Vaccination should be made readily available to all HCP. Methods to extend the availability include provision of the vaccination free of charge, off-hours clinics, mobile vaccination carts, and vaccination at departmental/faculty meetings. Some facilities have used 'drive through' vaccination clinics.

Education: Educational tools can be used to inform employees about the benefits of vaccination and the associated risks of refusal. By assessing comprehension about the vaccination, facilities can attempt to combat myths that may influence vaccination uptake. Concerns regarding poor efficacy and safety can be adequately addressed using targeted education.

Reporting and Monitoring: By tracking individual HCP and facility wide vaccination compliance, targets can be set and declinations or exemptions (if allowed) can be comprehensively addressed. Furthermore, surveillance of healthcare-associated influenza infections can be performed.

Barriers to refusal: By making the vaccination mandatory or by making getting the vaccine easier than refusing, vaccination coverage targets are more likely to be met. Implementing signed declination statements and stipulating vaccination as a condition of employment have shown the greatest effect in increasing HCP vaccination coverage.

Facilities have traditionally tried a range of interventions to increase influenza vaccination rates including educational programs, publicity campaigns, incentives, declination statements and mandates with varying consequences for non-compliance including termination of employment. While most reported interventions have had some impact on vaccination rates, mandatory programs have been shown to be the most effective method to achieve and sustain vaccination rates over 90%.

It is clear from Figure 1 that even with the implementation of declination letters and incentives, the overall vaccination uptake is still subpar. Declination letters saw an overall vaccination coverage of 65%, whilst the highest the incentive raffle saw was 42%. This can be compared to the 98-99% vaccination coverage achieved through mandatory vaccination. Since this publication, other facilities have reported similar results.

Figure 1.

Relative Impact of Various Strategies on Health Care Worker Influenza Vaccination Coverage

What are the key conclusions from available clinical trials or meta-analyses related to HCW Influenza vaccination programs that guide infection control practice and policies?

The currently available influenza vaccines have variable efficacy depending on the match of the circulating strains to the vaccine and the host immune response of the studied population. There is broad agreement that a better vaccine is needed. Until that vaccine is available, most national guidelines and position statements support the recommendation for all HCP to receive the influenza vaccine. HCP are in general healthier and often younger than their patients and are therefore more likely to have a good response to the influenza vaccine. By being vaccinated themselves and lowering their own risk for influenza infection, they also decrease the risk of transmitting influenza to those around them, including patients.

There is some debate about the level of impact that HCP influenza vaccination has on patient outcomes and about the use of mandates that include loss of employment as a potential consequence for HCP who choose not to be vaccinated.

What are the consequences of ignoring key concepts related to HCW Influenza vaccination programs?

In addition to HCP risk of acquiring influenza in the community, HCP are at a heightened exposure risk through their professional work with ill patients. This increased exposure can be further conferred to the close contacts of healthcare workers; including their family, friends and most applicably, other patients. The most efficient method in preventing this ‘domino effect’ of transmission is through pre-exposure vaccination.

Routine influenza vaccination of HCP can reduce both influenza-related illness and its potentially serious complications amongst HCP and their patients. Whilst nosocomial influenza rates are difficult to measure appropriately for acute care settings with shorter lengths of stay, in the context of nursing homes, several studies have shown that vaccination of HCP has decreased morbidity and mortality amongst nursing home residents. Furthermore, absenteeism has been shown to be reduced with routine vaccination of healthcare workers.

Summary of current controversies regarding HCW Influenza vaccination programs

There is broad support for routine influenza vaccination of HCP. The two main areas of controversy are around the need to reach high levels of vaccination with a vaccine of variable effectiveness and around whether mandates are a justifiable method to reach high vaccination rates. While mandatory vaccination is the most effective method for achieving high levels of vaccination coverage, there are concerns about the sacrifice of worker autonomy in the process. Multiple reviews of the medical ethics of mandatory programs have been published discussing the balance of the ethical principles of autonomy and beneficence.

What statements and guidelines exist that address HCP influenza vaccination?

As noted, the CDC and ACIP recommend annual influenza vaccination for all HCP. CDC tracks annual HCP vaccination rates through surveys and also through NHSN reporting by facilities. They also assess and report vaccine efficacy in the population every year. The CDC does not endorse any specific methods to achieve high levels of vaccine coverage among HCP.

Many medical and infectious disease societies have come out in support of mandatory vaccination. The American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Hospital Association, American Public Health Association, Association for Professionals in Infection Control, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, and other leading bodies in healthcare have all issued support for mandatory influenza vaccination of healthcare professionals. The immunization Action Coalition now recognizes over 500 facilities as ‘honorees’ that have Influenza Vaccination Mandates. http://www.immunize.org/honor-roll/influenza-mandates/

Some organizations have come out in opposition to the use of mandates to increase vaccination rates, though not in opposition to HCP influenza vaccination. These include the Association of Occupational Health Professionals in Healthcare and several labor union organizations.

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