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Over
the past decade, there has been increased promotion
of influenza vaccine, as well as increased access and
availability, in both medical settings and non-traditional
community settings. The US Healthy People 2010 coverage
goals look to achieve vaccination rates of 90% in persons
>65 and nursing home residents.1
Data from the National Health Interview Survey in 20062
and the CDC Behavioral Risk Data Surveillance system
in 20053
found that vaccination rates for these groups were 66%
and 65%, respectively—representing substantial
increases over previous years. Further, vaccination
promotion has increasingly become part of patients'
interaction with the healthcare system: the interventions
studied (and reviewed herein) include the institution
of standing orders during inpatient admissions (Dexter),
engaging staff as vaccination promoters in long-term
care facilities (Hayward), and implementing a patient
assessment and vaccination reminder system in outpatient
clinics (Fishbein).
Expansion of Influenza Indications
The 2007 recommendations for influenza vaccination were
recently published by the CDC, and represent a continued
expansion of influenza vaccination to near universal
levels.1
As condensed below, the CDC currently recommends vaccination
for:
- All persons, including school-aged children,
who want to reduce the risk of becoming ill with
influenza or of transmitting influenza to others
(in effect, a recommendation for universal vaccination);
- All children age 6 months through 4 years;
- All persons >50 years;
- Women who may be pregnant during the influenza
season;
- Adults and children with a variety of chronic
diseases;
- Adults and children with immunosuppression, either
caused by innate disease and/or medications, or
by infections such as HIV;
- Adults and children with respiratory compromise
(chronic pulmonary condition or risk for aspiration);
- Residents of nursing homes and long-term care
facilities;
- Healthcare personnel;
- Health household contacts of any of the above
groups with chronic illness or other indication.
A Move to Improve Vaccination Rates Among Healthcare
Workers
While the current recommendations include stronger language
regarding vaccination of healthcare workers, who have
been in the past been identified as a priority group,
the CDC document recognizes the challenges inherent
in achieving compliance: "Although annual vaccination
is recommended for HCP and is a high priority for reducing
morbidity associated with influenza in health care settings
and for expanding influenza vaccine use, national survey
data indicate a vaccination rate of only 42% in HCP."1
Consistent with the CDC data, an article by Hofmann
et al in Infection,4
reviewed the literature of healthcare workers' attitudes
and beliefs towards vaccination, and found that, as
of 2005, most reporting institutions in the US had uptake
rates no higher than 50%. One key structural barrier
identified is the lack of free vaccine - primarily an
access issue, which by in large has been ameliorated
by the implementation of employer-based and workplace-based
free vaccination programs. The authors further identified
a number of attitudinal barriers to developing effective
workplace vaccine programs, including a perceived lack
of vaccine efficacy, a fear of adverse reactions, and
a misperception about the severity and transmissibility
of influenza. Specific results from the various studies
show that 8-54% of respondents feared adverse events,
45% feared getting influenza from the vaccine, 6-58%
believed they were not at risk, and 3-32% considered
the vaccine to be ineffective. The authors recommend
that educational campaigns address these concerns. The
studies conducted over the past 3 years by Gazmararian,
Kimura, Christini, and Tapiainen (reviewed herein) show
that these patterns and attitudes continue, are found
in a variety of health care settings, appear to be most
prevalent among nurses and ancillary staff, and have
persisted despite vaccine education and outreach campaigns.
Policy Impact—A Call For Mandatory Vaccination
Because of the difficulty in implementing influenza
vaccine in employees, there has been an increasing call
for mandatory vaccine. In the heart of this controversial
issue are Dr. Gregory Poland5
from Mayo Clinic and Howard Backer from California Department
of Health Services.6
Poland and Backer have stated that - based on the facts
that influenza is a serious disease, that health care
workers can transmit the disease, that flu vaccine prevents
worker disruption and saves money - prevention of influenza
is an element in the standard of care, and, therefore,
healthcare workers and healthcare systems have an ethical
duty to vaccinate. Going even further, Poland suggests
that unless healthcare workers and healthcare systems
take responsibility for curbing epidemics and, in particular,
eliminating nosocomial influenza transmission, they
will be forced to do so through regulation.
Data accumulated over the past decade clearly show that
providing structural interventions in the medical practice
setting, large scale vaccine promotion, and increased
access have substantially increased vaccination coverage
among patient populations, and there is clear movement
towards universal vaccination. However, aggressive promotion
of vaccine in healthcare workers (HCWs) appears to have
limited impact. While the current ACIP recommendations
suggest that "active declination" or other types of
"opt out" measures should be implemented, it is very
likely these would result in pushback from employees.
As the data presented in this issue show, there are
clearly misperceptions about influenza vaccine in subsets
of HCWs that present major challenges, indicating a
pressing need to research the basis of these beliefs
and develop effective interventions.
References
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