Influenza Vaccination of Health Care Workers: Seven Truths

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Influenza Vaccination of Health Care Workers
Seven Truths
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Acknowledgement

• Greg Poland, Mayo Clinic
• Adapted from Poland GA, Tosh P, and Jacobson
  RM. Requiring influenza vaccination for health
  care workers seven truths we must accept.
  Vaccine 23 (2005) 2251-2255.

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Influenza

• Respiratory Infection
• Spread through contact with an infected person
  during coughing and sneezing
• 1 to 5 days from exposure to onset of symptoms
• Infectious up to 24 hours before symptoms appear
• Occurs October through April in North America

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Influenza Symptoms

• Rapid onset of
• fever
• chills
• body aches
• sore throat
• non-productive cough
• runny nose
• headache

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Influenza Is Not

• The stomach flu
• Cause of diarrhea
• Transmitted by ingestion of contaminated food
• Treated with antibiotics

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So

• If you develop the stomach flu or diarrhea
  after getting an influenza vaccineit doesnt
  mean the vaccine didnt workthat is not what it
  protects against!

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Influenza Diagnosis

• Clinical and epidemiological characteristics
• Isolation of influenza virus from clinical
  specimen
• Significant rise in influenza IgG by serologic
  assay
• Direct antigen testing

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Influenza Virus Strains

• Type A
• moderate to severe illness
• animals and humans
• all age groups
• Type B
• milder epidemics
• humans only
• primarily affects children
• Type C
• no epidemics
• rarely reported in humans

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Influenza Virus Composition
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Influenza Illness The Tip of the Iceberg
Influenza Illness
- Misery - Absenteeism - Physician Visits -
Antibiotic Use - Hospitalizations - Deaths
Exacerbations of chronic diseases Secondary
infections Other
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Complications of Influenza are Common
Belshe RB et al. Pediatr Infect Dis J 2000 19
S66. Kaiser L, et al. Arch Intern Med 2000 160
3234. Kaiser L, et al. Arch Intern Med 2003 163
1667.
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Influenza Epidemics Cause Seasonal Increases in
Hospitalizations
Thompson et al. JAMA 2004 292 1333.
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Excess Hospitalizations Are High in Young
Children the Elderly
Excess Hospitalizations Per 100,000 Healthy
Persons
MMWR 2003 52 (RR-13) Neuzil et al. NEJM 2000
342 225. Barker et al. Am J Epidemiol 1980 112
798.
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Epidemic Influenza Continues to Have a Huge
Annual Impact
Estimates for the US

• Cases 25 50 million cases
• Days of illness 100 200 million days
• Work school loss Tens of millions
• Hospitalizations 85,000 550,000
• Deaths 34,000 51,000
• Costs Billions of dollars

Ave respiratory circulatory 294,000 1979-80
thru 2000-01 Ave all cause, 1976-77 thru
1998-99. Ave all cause 1990-91 thru
1998-99. MMWR 2003 52 (RR-8) Thompson et al.
JAMA 2003 289 179 Thompson et al, JAMA 2004
292 1333 Adams PF et al. Vital Health Stat
1999 10(200).
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Influenza is the Leading Cause of Death Due to
Vaccine Preventable DiseasesCases Deaths, US
1989 - 1998
11k from 1989-98 (actual is 5x to 10x
higher)
MMWR 2001 48 (RR-53) Thompson et al. JAMA 2003
289 179 Feikin DR, et al. Am J Public Health
2000 90 223-9.
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Influenza Vaccines A Trivalent Defense
Type AH3N2
Type AH1N1
Influenza Protection
Influenza Protection
Type B
CDC. MMWR Morb Mortal Wkly Rep.
200352(RR-8)1-34.
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Inactivated (TIV) and Live Attenuated (LAIV)
Influenza Virus Vaccines Two Options for
Preventing Influenza
MMWR 2003 52 (RR-13) FDA approves FluMist for
use in younger ages, September 19, 2007
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WHO Global Influenza Surveillance Network

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Influenza Vaccine Production is an 8 to 9 Month
Process
Feb
Jan
Mar
Apr
Jun
May
Jul
Aug
Oct
Sep
Nov
Dec
Production of Concentrates
Eggs
Formulation-TestingFDA Release
Filling-TestingPackaging
Distribution
Administration
Need to Know
ACIP recommendations for use
One or more strains in formula
Precise formulation
All strains in formula
Courtesy of the Centers for Disease Control and
Prevention. The characteristics of the strains
circulating the previous season provide the
basis for selecting virus strains for the next
years vaccine.
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Influenza Vaccine

• Composition
• Inactivated virus Split (subvirion)
  Trivalent (H3N2, H1N1,B)
• Efficacy
• Varies by similarity to circulating strain, age,
  underlying illness
• Duration of Immunity
• lt1 year
• Schedule--1 dose annually

2 doses for first vaccination of children lt9
years
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Did you know?

• Because the influenza vaccine is made with an
  inactivated virus that you CANT get flu from
  the vaccineit is impossible

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Influenza Vaccine

• Up to 90 effective in preventing clinical
  illness in young, healthy adults
• 30-40 effective in preventing illness among
  frail elderly
• 50-60 effective in reducing hospitalization
• Up to 75 effective in preventing death

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Influenza vaccination recommendations

• Persons at high risk of hospitalization or death
  due to influenza complications
• Persons 50 years
• Infants 6 59 mos
• Pregnant women-
• regardless of stage of pregnancy

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Influenza vaccination recommendations

• Persons at high risk of complications cont.
• Persons 2-18 on long term aspirin therapy
• Persons who live in a long term care facility
• Persons 2-64 years with a chronic medical
  condition
• Heart disease
• Lung disease including asthma
• Kidney disease
• Metabolic disease
• Immunosuppression
• Blood disorders

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Influenza vaccination recommendations

• Persons who will be in contact with those at risk
  for complications
• HCWs and facility staff
• Household contacts of all persons in the fore
  mentioned risk groups
• Household contacts of infants less than 6 months
  of age
• Out-of-home caregivers of infants less than 6
  months of age

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Live Attenuated Influenza Vaccine

• FluMist FDA-approved June 2003
• Stringent storage requirements
• Indicated for healthy persons, aged 2-49
• Specifically contraindicated for persons with
  chronic illness
• Given intranasally, 0.25 in each nostril

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FluMist as a live virus vaccine

• Cold adapted cannot replicate/survive in the
  warm temperatures of the lower respiratory tract
• Attenuated will not grow well on human tissue
• Requires all 6 antigenic segments to revert to
  original configuration in order to cause disease
• Requires significant viral load in order to be
  considered an infective dose

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In other words

• You cannot get the flu from a FluMist
  vaccination. FluMist is a live, attenuated virus
  that cannot replicate at body temperature and
  cannot cause the flu.
• In FluMist the live influenza virus has been
  weakened so that it cannot cause infection.
• Viral virulence factors have been altered,
  removing its ability to cause infection.
• Cannot reproduce at temperatures above 37-39OC,
  the temperature of human lungs and lower airway.
  The FluMist virus cannot survive in lungs,
  bloodstream, or deeper parts of the body.

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FluMist No Transmission

• Observed risk of transmission causing disease is
  zero
• There is a lack of relationship between shedding,
  transmission and disease

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In other words

• It is harder than it seems to transmit the
  vaccine virus.
• In order for a FluMist recipient to spread virus
  that then causes a clinical infection in others
• The person must shed the virus from their nose.
• The amount of virus shed must be large enough to
  cause spread of infection.

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In other words

• If the FluMist virus is spread to another person,
  it must become able to reproduce in the
  temperature of the lower airways.
• After the first three steps occur then the
  FluMist virus would have to regain its ability to
  cause disease.
• There have been no instances of symptomatic
  transmission of the vaccine virus in adults.

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LAIV indications

• HCW who have received LAIV should refrain from
  contact with severely immunocompromised persons
  who require a protective environment (e.g. bone
  marrow transplants) for 7 days
• Persons who have contraindications for receiving
  LAIV may administer LAIV
• An assumption that they have been vaccinated
• Severely immunocompromised should not administer
  LAIV

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Only 36 of US Health Care workers received
influenza vaccination in 2002
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Even among health care centers utilizing
aggressive campaigns to promote HCW immunization,
30-50 remain unvaccinated.
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Why havent YOU gotten vaccinated against
influenza?
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Seven Truths
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The first truth

• Influenza infection is a serious illness causing
  significant morbidity and mortality adversely
  affecting public health on an annual basis

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Influenza is a serious disease

• Sixth leading cause of death among adults in the
  US killing an average of 36,000 Americans
  annually
• Influenza kills as many or more people than
  breast cancer (40,000) and 3x as many as HIV/AIDS

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Influenza is a serious disease

• 1 of 20 deaths in persons 65 or older is related
  to influenza
• Direct annual cost of influenza infection is 3
  to 5 billion dollars in the US

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The second truth

• Influenza infected health care workers can
  transmit this deadly virus to their vulnerable
  patients

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HCWs can transmit disease

• Influenza virus can be transmitted by both
  symptomatic and asymptomatic HCWs
• Simply staying home from work is insufficient for
  preventing nosocomial transmission.

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HCWs can transmit disease

• Multiple studies have shown that health care
  workers continue to work despite being ill with
  influenza!

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Influenza A Outbreak Neonatal Unit (1998)

• 19 of 54 patients tested positive for influenza A
• 6 were symptomatic, 1 died
• Of the 150 medical staff, only 15 had received
  the flu vaccine 67 of physicians and 9 of
  nurses
• Only 29 of staff with symptomatic influenza took
  time off work!

Cunney et. al, Infection Control Hosp Epidemiol
2000
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HCWs can prevent disease

• Influenza immunization of health care workers
  protects vulnerable patients, improves patient
  safety, and can significantly decrease morbidity
  and mortality

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Scottish Study (2000)

• Compared mortality rates between long-term care
  hospitals that offered influenza vaccination to
  HCWs (51 vaccinated) with those that did not (5
  vaccinated)
• 40 reduction in all-cause mortality among the
  patients cared for by HCWs in the hospitals with
  higher levels of HCW vaccination

Carman WF et. al, Lancet 2000
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HCWs can prevent disease

• The National Quality Forum, a voluntary consensus
  health care standard setting organization, lists
  influenza immunization of HCWs as 1 of 30 safe
  practices that should be universally implemented
  to reduce risk of harm to patients

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The third truth

• Influenza vaccination of health care workers
  saves money for employees and employers and
  prevents workplace disruption

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Benefits of HCW vaccination

• Healthy working adults who receive influenza
  vaccination have
• 25 fewer upper respiratory infections,
• 44 fewer doctor visits, and
• 43 fewer sick days off
• Saving 47 per person annually
• Nichols KL et. al, N Engl J Med 1995

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Benefits of HCW vaccination

• 3 different cohorts of 25,000 adults studied over
  3 years found
• Pneumonia hospitalizations reduced by 48-57
• Acute and chronic respiratory conditions reduced
  by 27-39 and
• All cause mortality reduced by 39-52
• Direct savings per year averaging 117/person
  immunized
• Nichols KL et. al, N Engl J Med 1994

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Influenza impact on acute care

• CDC survey of 221 hospitals from December 2003 to
  February 2004 found
• 35 reported staffing shortages during flu peak
• 28 reported bed shortages
• 43 reported ICU bed shortages
• 9 reported diversion of patients to other
  facilities for a mean of 6 days

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The fourth truth

• Influenza vaccination of health care workers is
  already recommended by the CDC and is the
  standard of care

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Standard of care

• Since 1981, the CDC has recommended health care
  worker vaccination as part of the the ACIP
  recommendations for influenza vaccination.

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The fifth truth

• Immunization requirements are effective and work
  in increasing vaccination rates

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Vaccine requirements

• School entry requirements have resulted in
  childhood immunization rates often exceeding
  90-95
• Rubella and hepatitis requirements have been
  successful in achieving nearly universal HCW
  vaccination against these pathogens
• Requirements for MMR vaccination and TB screening
  have resulted in improved patient safety

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The sixth truth

• Health care workers and health care systems have
  an ethical and moral duty to protect vulnerable
  patients from transmissible diseases

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Ethical and Moral Duty

• OSHA and JCAHO support the idea of protecting
  HCWs and patients by vaccination
• The medical community has an ethical obligation
  to act with the safety of its patients as its
  foremost interest.
• Health care workers are vectors for influenza

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Ethical and Moral Duty

• Influenza vaccination of HCWs protects patients
  from influenza and decreases mortality
• The influenza vaccine is safe
• Knowing these facts and not acting upon them is a
  dereliction of the responsibilities of the
  medical community to the safety of the public
  with whose care they are entrusted

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The seventh truth

• The health care system will either lead or be
  lambasted

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Do the right thing

• Reports of nosocomial influenza outbreaks have
  begun to surface in the popular mediaas the
  public becomes aware that HCWs are largely
  unvaccinated the health care system will lose
  credibility

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Do the right thing

• What about contraindications to vaccination? Even
  with a small percentage of individuals unable to
  be vaccinated, herd immunity will still protect
  unimmunized HCWs and their patients
• We dont want to bring disease home to our
  families and community

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Do the right thing

• Influenza vaccination of HCWs is the right thing
  to do.
• It benefits the patient, the employee, and the
  employer.
• The health care profession has the opportunity to
  demonstrate that we WILL do the right thing for
  our patients!

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In summary
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Summary

• Influenza infection is a serious illness causing
  significant morbidity and mortality
• Influenza infected HCWs can transmit disease to
  their vulnerable patients
• Influenza vaccination of HCWs saves money
  prevents workplace disruption

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Summary

• Influenza vaccination of HCWs is already
  recommended by the CDC and is the standard of
  care
• Immunization requirements are effective and work
  in increasing vaccination rates

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Summary

• Health care workers and health care systems have
  an ethical and moral duty to protect vulnerable
  patients from transmissible diseases
• The health care system will either lead or be
  lambasted

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So, are YOU going to get vaccinated against
influenza????
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Employee influenza vaccination clinic information