Influenza vaccination of healthcare personnel

Abstract

The thought is terrifying—you are admitted to the hospital and you die of a nosocomial infection. What sounds like a horror scenario, happens every day in hospitals all over the world. Nosocomial influenza is associated with considerable morbidity and mortality among patients with underlying diseases (especially immunocompromised patients), the elderly, and neonates. Although vaccination of healthcare personnel (HCP) is the main measure for preventing nosocomial influenza and is consistently recommended by public-health authorities, vaccine uptake among HCP remains low.¹

Keywords:

• influenza
• vaccination
• immunization
• healthcare workers
• healthcare personnel
• mandatory

The study of Bonaccorsi et al. demonstrated influenza vaccination rates between 15% and 18% for pandemic and seasonal influenza respectively. The influenza vaccination rate in the intensive care unit (ICU) was 13.4%.² From an infection control point of view, these rates are truly alarming. The authors suggested measures for improving vaccination rates like “eliminating organisational barriers,” “mobile vaccination carts,” and further education. This certainly sounds reasonable at the first glance.

However, although some voluntary HCP vaccination programs have been effective when combined with strong institutional leadership and long-standing educational campaigns, mandatory influenza vaccination programs seem to be the most effective way to increase HCP vaccination rates.³ In December 2013 the Infectious Disease Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society (PIDS) published a statement that “Mandatory immunization programs are necessary where voluntary programs fail to maintain adequate HCP vaccination rates.”³

A current systematic review of randomized trials, cohort studies and case-control studies draw the conclusion that “HCP influenza vaccination can enhance patient safety.”⁴

Undoubtedly, it is important to understand why HCP do not accept influenza vaccination. Understanding is the first step to improve vaccination rates. However, the time has come to put patient safety and quality of care over the reluctance of HCP to get vaccinated against influenza. Continued calls for “more education” for 3 decades were doomed to fail as numerous articles can demonstrate. Whether mandatory vaccination programs are justified is fundamentally an ethical issue, as we have to balance the benefits and harm vis-à-vis the patients and residents on the one hand and the restriction of autonomy and the influenza vaccination associated benefits and burdens on behalf of the HCP on the other hand.^5,6

Ideally, HCP will take individual responsibility for being fully immunized. When this does not happen, laws and regulations need to be implemented in order to protect the most vulnerable members of our society. The goal of an occupational vaccination program is to prevent infection of HCP and transmission to patients—there is a close link between HCP safety and patient safety. If mandatory vaccination programs are implemented, the institution's personnel should be involved in the decision process.⁶ While it is usually assumed that HCP oppose to mandatory policies, we found in our survey in a German University Hospital that 68.4% believed that mandatory vaccinations for HCP were appropriate, with an even higher support among physicians vs. nurses (78.1% vs. 63.1%).⁷ However, acceptance differed depending on the disease with higher support rates for when self-protection is more important to HCP. Mandatory vaccination against seasonal influenza was accepted by 43.5%, 22.3% of HCP supported mandatory vaccinations for HCP who care for immunocompromised patients and only a quarter (24.8%) found mandatory influenza vaccinations for HCP unacceptable. In addition, 70.6% of HCP would prefer that only HCP with measles immunity care for their child if she could not receive the measles vaccination due to an oncological disease. In light of these apparently high acceptance rate of mandatory vaccinations among HCP, it could turn out that a majority of HCP would support voluntarily a policy of mandatory influenza vaccination if they were well-informed and included into the decision making process about the mandatory policy. Bonaccorsi et al. have pointed out that we “need to strengthen the knowledge about the risk related to influenza among the students, who will be the future HCP.” That is certainly right—but it is not enough!

Disclosure of Potential Conflicts of Interest

S.W. is a member of the German Standing Committee on Vaccination (STIKO). She has received honoraria for non-product-related talks on influenza vaccination from GlaxoSmithKline, Sanofi Pasteur, AstraZeneca and Novartis and has participated in workshops about health care workers and vaccination sponsored by Abbot. G.M. participated in 2010 in a workshop about health care workers and vaccination sponsored by Abbot. The views in this article are the personal views of the authors and do not necessarily represent the views of the professional organizations or institutions within which we are members.