Blog | Monday, February 1, 2016

End or beginning for mandatory influenza vaccination of health care workers?


“Just don't let the human factor fail to be a factor at all”
—Andrew Bird, Tables and Chairs

We are all in favor of protecting patients from preventable harm. No question. With that aim, the intervention du jour (in the U.S.) is mandatory influenza vaccination of health care workers. Society for Healthcare Epidemiology of America, Infectious Diseases Society of America, and Pediatrics Infectious Disease Society of America support such a policy, yet a recent Cochrane review stated ”there is no evidence that only vaccinating health care workers prevents laboratory-proven influenza or its complications (lower respiratory tract infection, hospitalization or death due to lower respiratory tract infection) in individuals aged 60 or over in LTCIs [long-term care institutions] and thus no evidence to mandate compulsory vaccination of health care workers.”

Yet given the inevitability of mandatory influenza vaccine policies in the U.S., what can we do to protect our patients from health care-acquired influenza and other viral illnesses since mandates would be expected to have minimal or even negative effects on nosocomial influenza transmission? To explain this further, compulsory vaccination policies are technical interventions which are relatively simple to implement. But we have seen over and over that ignoring the human equation or socio-adaptive factors behind infection prevention initiatives leads to failure. As Sanjay Saint and Sarah Krein have written eloquently in their recent book: ”Our research has shown that the principle reason is the failure of the hospitals to win their staff's active support of the infection prevention initiatives. In their focus on the technical aspects of an initiative, these hospitals have given short shrift to the human aspects.” (You can read my Doody review of their book at Barnes & Noble here.)

What are the additional components that we need to consider when implementing an influenza vaccine mandate? Some suggestions:
1. First, acknowledge that we know the vaccine is imperfect through the develop of communication strategies that highlight the proven benefits of the influenza vaccine to the individual health care worker. Since the data supporting direct benefits to patients is more theoretical at this point, highlighting the protective effects for the individual receiving the vaccine - including reduced risks of cardiovascular outcomes could improve acceptance of the mandate.
2. Next, mandate additional components in our influenza prevention bundle, especially those highlighted in the Cochrane review which included “hand-washing, masks, early detection of influenza with nasal swabs, antivirals, quarantine, restricting visitors and asking health care workers with an influenza-like illness not to attend work.”
3. Offer additional sick leave to health care workers required to receive the vaccine. Policies that include bans on presenteeism (working while sick), should be accompanied by additional paid sick leave. In this specific instance, influenza vaccine is associated with fever (especially high-dose vaccines that are associated with benefits in older adults). Providing additional sick leave shows our understanding of vaccine side-effects, demonstrates support for staying home sick and most importantly, respects the individual health care worker.
4. Include in the mandate bundle a plan to de-implement the vaccine mandate if future studies demonstrate that they're ineffective. Doing this will gain more trust with our health care workers, which may, counterintuitively, improve the effectiveness of the mandate.
5. Finally, fund large studies evaluating the efficacy, effectiveness and implementation (i.e. barriers) of influenza vaccine mandates in our health care systems. Funding research acknowledges that the data around vaccine mandates isn't perfect, but we are doing the best we can to protect patients now, while simultaneously validating the safety and efficacy of this policy to protect future generations of patients and our health care workers.

There are many things we need to consider as we implement mandatory influenza vaccine policies. The mandate is just the beginning. We have a long road ahead before we can state convincingly that our hospitals are safe from hospital-acquired influenza.

“And how
How I wish
I, I had talked to them
And I wish they fit into the plan”
—Andrew Bird, Tables and Chairs

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.