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Invited Commentary
Infectious Diseases
June 1, 2018

Continuing to Move the Needle on Health Care Personnel Influenza Vaccination Rates

Author Affiliations
  • 1Washington University School of Medicine, St Louis, Missouri
  • 2Infection Prevention and Epidemiology Consortium, BJC HealthCare, St Louis, Missouri
JAMA Netw Open. 2018;1(2):e180144. doi:10.1001/jamanetworkopen.2018.0144

Influenza vaccination of health care personnel (HCP) is a key part of any influenza management plan, along with hand hygiene, early identification and isolation of affected patients, adherence to isolation policies, appropriate use of personal protective equipment, discouragement of presenteeism among symptomatic HCP, and visitor screening. The Centers for Disease Control and Prevention Healthy People 2020 initiative set a goal of greater than a 90% vaccination rate among HCP. Over the last decade, as facilities across the United States have used a range of strategies to reach that target level, it has become clear that the most effective way to achieve and sustain a high vaccination rate is with an institutional requirement.1,2

Greene et al3 evaluate changes in the prevalence of facility mandates for HCP influenza vaccination for the last 4 years. Building on a multiyear survey of infection preventionists about infection prevention practices, the May 2017 survey included the question, “Does your hospital mandate health care workers to receive annual influenza vaccination?” with additional questions about requirements for wearing masks and declination statements. Greene et al3 found that compared with the prior survey in 2013,4 use of mandatory influenza vaccination policies in the surveyed population increased from 37.1% to 61.4%; the change was driven almost exclusively by increases at non–Veterans Affairs (VA) hospitals (44.3% in 2013 to 69.4% in 2017), as there was little change at VA hospitals (1.3% in 2013 to 4.1% in 2017).

There are a few caveats to these findings. The random sample for this survey includes different facilities than in the 2013 survey and includes smaller hospitals, so direct comparisons cannot be made. However, in the prior survey there was evidence of anticipated increased use of mandates, as 4% were discussing mandates, approximately 10% said they would have one next season, and 21% endorsed having a declination policy (signed form and/or requirements for wearing masks). In addition, the survey question was worded somewhat differently in the 2013 survey, which could affect the answers provided, and vaccination rates were not reported. Most importantly, it does not appear that mandate was defined. Among respondents who reported having a vaccination mandate, only 74% reported having penalties for noncompliance and 13% allowed declination without a specified reason. Of those reporting no mandate, 21% reported penalties for noncompliance with hospital policy on influenza vaccination and 41% reported requirements for wearing masks if unvaccinated. An article in a bioethics journal5 offers the following criteria for using the term mandate in this setting: limiting acceptable reasons for refusal, penalizing nonparticipation, and enforcing these expectations. By these criteria, it is not clear how many programs described in this survey should appropriately be referred to as mandatory—the number may be higher or lower than that reported, although an increase over time seems likely.

A limitation of studies on influenza vaccination of HCP is the lack of data on patient outcomes.6 While a few retrospective studies have shown correlations between increases in HCP influenza vaccination and decreases in nosocomial influenza in acute care settings,7-10 these data are limited. There are many reasons that measuring relevant patient outcomes and clearly associating them with HCP influenza vaccination rates can be challenging, including variability in infection prevention practices, nonspecific symptoms in many inpatients owing to comorbidities, variability in influenza community prevalence and in vaccine effectiveness every year, short lengths of stay in the hospital, and the difficulty in capturing postdischarge illnesses. However, an excellent opportunity now exists to address these knowledge gaps. Greene et al3 note that the VA system has announced a directive stating that all HCP are expected to receive the influenza vaccine and are required to wear masks during influenza season if unable or unwilling to be vaccinated. The VA system includes a large number of facilities of varying bed sizes and locations, so their experience will be more generalizable than a single-center experience. Most importantly, patients in the VA system often receive all of their care, inpatient and outpatient, within the system. Here is an opportunity to evaluate outpatient and emergency department visits for respiratory viral infections and laboratory-confirmed influenza occurring after hospital discharge in addition to nosocomial influenza infection in inpatients and HCP absenteeism.

The use of mandates is increasing, and HCP influenza vaccination rates are increasing. While the assumption that decreasing the risk of influenza in HCP will result in decreased risk of influenza in patients cared for by those HCP is common sense, for acute care settings, it is still largely an assumption. Hopefully, the Veterans Health Administration will combine this initiative with thoughtful, planned, patient outcome assessments to help define the anticipated benefit of these efforts.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Babcock HM. JAMA Network Open.

Corresponding Author: Hilary M. Babcock, MD, MPH, Washington University School of Medicine, 4523 Clayton Ave, Campus Box 8051, St Louis, MO 63110 (hbabcock@dom.wustl.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Nowalk  MP, Lin  CJ, Raymund  M, Bialor  J, Zimmerman  RK.  Impact of hospital policies on health care workers’ influenza vaccination rates.  Am J Infect Control. 2013;41(8):697-701.PubMedGoogle ScholarCrossref
2.
Black  CL, Yue  X, Ball  SW,  et al.  Influenza vaccination coverage among health care personnel—United States, 2016-17 influenza season.  MMWR Morb Mortal Wkly Rep. 2017;66(38):1009-1015.PubMedGoogle ScholarCrossref
3.
Greene  MT, Fowler  KE, Ratz  D, Krein  SL, Bradley  SF, Saint  S.  Changes in influenza vaccination requirements for health care personnel in US hospitals.  JAMA Netw Open. 2018;1(2):e180143. doi:10.1001/jamanetworkopen.2018.0143Google Scholar
4.
Greene  MT, Fowler  KE, Krein  SL,  et al.  Influenza vaccination requirements for healthcare personnel in US hospitals: results of a national survey.  Infect Control Hosp Epidemiol. 2016;37(4):485-487.PubMedGoogle ScholarCrossref
5.
Wynia  MK.  Mandating vaccination: what counts as a “mandate” in public health and when should they be used?  Am J Bioeth. 2007;7(12):2-6.PubMedGoogle ScholarCrossref
6.
Pitts  SI, Maruthur  NM, Millar  KR, Perl  TM, Segal  J.  A systematic review of mandatory influenza vaccination in healthcare personnel.  Am J Prev Med. 2014;47(3):330-340.PubMedGoogle ScholarCrossref
7.
Salgado  CD, Giannetta  ET, Hayden  FG, Farr  BM.  Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians.  Infect Control Hosp Epidemiol. 2004;25(11):923-928.PubMedGoogle ScholarCrossref
8.
Bénet  T, Régis  C, Voirin  N,  et al.  Influenza vaccination of healthcare workers in acute-care hospitals: a case-control study of its effect on hospital-acquired influenza among patients.  BMC Infect Dis. 2012;12:30.PubMedGoogle ScholarCrossref
9.
Amodio  E, Restivo  V, Firenze  A, Mammina  C, Tramuto  F, Vitale  F.  Can influenza vaccination coverage among healthcare workers influence the risk of nosocomial influenza-like illness in hospitalized patients?  J Hosp Infect. 2014;86(3):182-187.PubMedGoogle ScholarCrossref
10.
Frenzel  E, Chemaly  RF, Ariza-Heredia  E,  et al.  Association of increased influenza vaccination in health care workers with a reduction in nosocomial influenza infections in cancer patients.  Am J Infect Control. 2016;44(9):1016-1021.PubMedGoogle ScholarCrossref
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