Mandatory Influenza Immunization Programs for HCWs

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Mandatory Influenza Immunization Programs for
HCWs What is the logic?

• Richard T. Ellison III, MD
• Professor of Medicine, Microbiology Molecular
  Genetics
• University of Massachusetts Medical School

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Influenza Immunization of all Healthcare Workers

• Now endorsed by IDSA, SHEA, CDC, AAP, APHA, ACP,
  APIC, NFID
• In 2010-2011 230 US hospitals required clinical
  healthcare workers to receive the influenza
  vaccine
• Medical exemptions were allowed at most
  institutions
• Some institutions allowed HCWs to decline
  vaccination but wear a surgical mask while in the
  hospital

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Does Mandatory Immunization of HCWs Make Sense?

• Are their benefits for patients to having
  healthcare workers immunized?
• Are their direct benefits to healthcare workers
  from being immunized?
• Is it necessary for hospitals to require
  healthcare workers to be immunized?
• Does it make sense to have non-immunized
  employees wear a mask?

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Are their benefits for patients to having
healthcare workers immunized?
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Impact of HCW Influenza vaccination in Long Term
Care Facilities

• Potter et al HCWs in 12 LTCFs randomized to
  offer HCWs flu vaccine for 1994-1995 season (1078
  HCWs, 1059 patients)
• 61 vaccination rate in offered facilities
• uncorrected mortality reduced (10 vs 17)
• J Infect Dis 19971751
• Carman et al HCWs in 20 LTCFs randomly offered
  flu vaccine for 1996-1997 season (1217 HCWs, 1437
  patients)
• 51 vs 4.9 HCW vaccination rate in offered vs
  non-offered facilities
• uncorrected mortality (13.6 vs 22.4)
• Lancet 200035593

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Impact of HCW Influenza vaccination in Long Term
Care Facilities

• Hayward et al HCWs in 44 LTCFs randomly offered
  flu vaccine over 2 years (1703 HCWs, 2604
  patients)
• 43 vs 3.5 HCW vaccination rate in offered vs
  non-offered facilities
• 27 reductions in overall mortality in 2003-2004
  during flu season but not in non-flu season, nor
  during the 2004-2005 season when there was
  decreased influenza activity nationwide
• BMJ 20061331241
• Lemaitre et al HCWs in 40 LTCFs randomly
  offered flu vaccine (3,483 patients)
• 70 vs 32 HCW vaccination rate in vaccination vs
  control facilities
• No reduction seen in unadjusted all cause patient
  mortality, but reduction in all cause mortality
  found in multivariate analysis (odds ration 0.8,
  95 CI 0.66-0.96) that included adjustments for
  resident age, vaccination status, disability
  score and comorbidity index
• J Am Ger Soc 2009571580

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Impact of Influenza in Acute Care Facilities

• Cunney et al 1998 flu outbreak in a Neonatal
  ICU
• 19 of 54 patients developed influenza 6 were
  symptomatic and 1 died
• Of 150 HCWs only 15 received flu vaccine only
  29 of symptomatic HCWs with influenza took time
  off from work
• Infect Control Hosp Epidemiol 200021449
• Weinstock et al 1998 flu outbreak in a Bone
  Marrow Transplant Unit
• 10 hospital acquired cases of influenza occurred
  in BMTU patients 6 developed X-ray evidence of
  pneumonia, and 1 died from pneumonia
• HCW immunization rate was 12 at time of
  outbreak, 5 HCWs were symptomatic with an
  influenza-like illness during the outbreak
• Infect Control Hosp Epidemiol 200021730

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Are their direct benefits to healthcare workers
from being immunized?
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• 849 healthy 18-64 YO adults randomized to receive
  influenza vaccine or placebo
• Vaccinated individuals had
• 25 fewer episodes of URIs
• 43 fewer sick leave days taken for URIs
• 37 fewer overall sick leave days
• 44 fewer physician visits for URIs
• 20 fewer days of URIs

All differences statistically significant
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INFLUENZA IMMUNIZATION OF HEALTHY ADULTS

• RANDOMIZED CONTROLLED TRIAL OF EFFECTIVENESS OF
  LIVE INTRANASAL INFLUENZA VACCINE FOR HEALTHY
  WORKING ADULTS
• 4561 enrolled in 1 year study vaccine
  recipients had fewer days of severe febrile
  illness, days of work lost, and fewer physician
  visits (JAMA 1999282137)
• RANDOMIZED CONTROLLED TRIAL ON EFFECTIVENESS AND
  COST-BENEFIT OF INFLUENZA VACCINATION OF HEALTHY
  ADULTS
• 2 year study (1184/1191 enrolled) in year 1
  vaccine efficacy was poor (50) and no benefit
  in year 2 vaccine efficacy was 86 and
  vaccination reduced ILI, physician visits, and
  lost workdays by 34, 42 and 32 (JAMA
  20002841655)
• RANDOMIZED TRIAL OF INFLUENZA VACCINE FOR
  HEALTHCARE WORKERS
• 3 year trial involving 264 HCWs with 359
  person-winters of surveillance
• 13.4 of control vs. 1.7 of vaccinated HCWs had
  serologic evidence of flu mean lost workdays 0.1
  for vaccinated HCWs vs. 0.21 for non-vaccinated
  HCWs (JAMA 1999281908)

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Does making influenza immunization mandatory for
HCWs make a difference?
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Virginia Mason Medical Center Seattle, WA
Year Percentage
Yr 2002 38.00
Yr 2003 54.00
Yr 2004 29.50
Yr 2005 98.00
Yr 2006 98.50
Yr 2007 99.00
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Employee Immunization BJC Healthcare
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What about wearing masks?
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Influenza virusis shed by infectedindividuals
prior to the onset of symptoms
Hayden et al. JAMA 19992821240
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Do Mandatory Influenza Vaccine Immunization
Programs for HCWs Make Sense?

• Are their benefits for patients to having
  healthcare workers immunized? YES
• Are their direct benefits to healthcare workers
  from being immunized? YES
• Is it necessary for hospitals to require
  healthcare workers to be immunized? ?
• Does it make sense to have non-immunized clinical
  employees wear a mask? YES

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