Should staff in long-stay hospitals for elderly patients be vaccinated against influenza?

Utility of Healthcare System-Based Interventions in Improving the Uptake of Influenza Vaccination in Healthcare Workers at Long-Term Care Facilities: A Systematic Review

Healthcare workers (HCWs) in long-term care facilities (LTCFs) can represent a source of influenza infection for the elderly. While flu vaccination coverage (VC) is satisfactory in the elderly, HCWs are less likely to be vaccinated. There is no definitive evidence on which types of healthcare system-based interventions at LTCFs would be more useful in improving the vaccination uptake among HCWs. We performed a systematic review in different databases (Pubmed, Cochrane Database of Systematic Reviews, Health Evidence, Web of Science, Cinahl) to provide a synthesis of the available studies on this topic. Among the 1177 articles screened by their titles and abstracts, 27 were included in this review. Most of the studies reported multiple interventions addressed to improve access to vaccination, eliminate individual barriers, or introduce policy interventions. As expected, mandatory vaccinations seem to be the most useful intervention to increase the vaccination uptake in HCWs. However, our study suggests that better results in the vaccination uptake in HCWs were obtained by combining interventions in different areas. Educational campaigns alone could not have an impact on vaccination coverage. LTCFs represent an ideal setting to perform preventive multi-approach interventions for the epidemiological transition toward aging and chronicity.

Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial

OBJECTIVE

To determine whether vaccination of care home staff against influenza indirectly protects residents.

DESIGN

Pair matched cluster randomised controlled trial.

SETTING

Large private chain of UK care homes during the winters of 2003-4 and 2004-5.

PARTICIPANTS

Nursing home staff (n=1703) and residents (n=2604) in 44 care homes (22 intervention homes and 22 matched control homes).

INTERVENTIONS

Vaccination offered to staff in intervention homes but not in control homes.

MAIN OUTCOME MEASURES

The primary outcome was all cause mortality of residents. Secondary outcomes were influenza-like illness and health service use in residents.

RESULTS

In 2003-4 vaccine coverage in full time staff was 48.2% (407/884) in intervention homes and 5.9% (51/859) in control homes. In 2004-5 uptake rates were 43.2% (365/844) and 3.5% (28/800). National influenza rates were substantially below average in 2004-5. In the 2003-4 period of influenza activity significant decreases were found in mortality of residents in intervention homes compared with control homes (rate difference -5.0 per 100 residents, 95% confidence interval -7.0 to -2.0) and in influenza-like illness (P=0.004), consultations with general practitioners for influenza-like illness (P=0.008), and admissions to hospital with influenza-like illness (P=0.009). No significant differences were found in 2004-5 or during periods of no influenza activity in 2003-4.

CONCLUSIONS

Vaccinating care home staff against influenza can prevent deaths, health service use, and influenza-like illness in residents during periods of moderate influenza activity.

TRIAL REGISTRATION

National Research Register N0530147256.

Épidémie de grippe nosocomiale dans un service de gériatrie

OBJECTIVE

To describe a nosocomial influenza outbreak and the pharmacologic and nonpharmacologic control measures implemented in a hospital ward with beds for acute geriatric care and rehabilitation care.

METHODS

Descriptive survey conducted in the geriatrics department of a university hospital. An influenza outbreak occurred in February 2005 in 2 of the department's 3 separate units. The study concerned all patients in the 2 affected units (A and B) present during the outbreak, as well as all department staff. Once cases of influenza were confirmed, elderly patients in contact with influenza patients received chemoprophylaxis with oseltamivir when it became available.

RESULTS

Thirty-eight (76%) patients and 62 (38%) staff members had been vaccinated. The time from the initial symptoms of the first case until implementation of control measures was 7 days in unit A but only 1 day in unit B, -and chemoprophylaxis of contact patients began in 9 days and 24 hours respectively. The attack rate was 38% in the 38 vaccinated patients and 29% in the 14 unvaccinated patients (NS). All cases met the definition of nosocomial infection. No deaths imputable to influenza occurred during the outbreak. The implementation of the nonpharmacologic measures aimed at preventing spread of the outbreak presented no particular difficulty, except for compliance with geographic isolation of some patients with dementia and influenza. The difference between the attack rates for the two sectors (48% for unit A and 28% for unit B) suggests that the preventive measures were effective. Tolerance to chemoprophylaxis with oseltamivir was good.

CONCLUSION

This study confirmed that influenza can affect elderly hospital patients, even those in whom the vaccination rate is high, and that rapid detection of the outbreak and immediate implementation of pharmacologic and nonpharmacologic preventive measures can limit its spread.

Chapter 4: Can Mandatory Vaccination of Health Care Professionals during an Influenza Pandemic ever be Justified?

Objectives: To discuss whether, during an influenza pandemic, public health authorities could be ethically justified in implementing a mandatory vaccination program directed at health care professionals.

Methods: Ethical analysis is carried out by examining arguments that can be made in favor or against such a mandatory measure and by seeking a reasonably balanced position between them. Arguments under consideration are based on the duties of health professionals and public health authorities, the consequences of their actions and on other ethical principles. The importance of relevant empirical data is stressed without any attempt to review or analyze them systematically.

Results: Mandatory vaccination of some health care professionals during a serious pandemic of influenza can be justified, but only under certain limited conditions.

Conclusions: In the throes of an influenza pandemic, health care professionals (and to a variable degree, other health care workers) have an ethical obligation to accept influenza vaccination if it is reasonably safe and effective. The ethical responsibility of public health authorities is to limit the impact of a pandemic on the population by all reasonable means, which clearly includes the appropriate use of vaccine. Consequently, the vaccination of health care staff can be made mandatory under certain conditions. However, a critical objection to this conclusion, which upholds that a voluntary vaccination program (an ethically much less problematic intervention) is just as effective, needs to be addressed.

Influenza vaccination in Dutch nursing homes: is tacit consent morally justified?

OBJECTIVES

Efficient procedures for obtaining informed (proxy) consent may contribute to high influenza vaccination rates in nursing homes. Yet are such procedures justified? This study's objective was to gain insight in informed consent policies in Dutch nursing homes; to assess how these may affect influenza vaccination rates and to answer the question whether deviating from standard informed consent procedures could be morally justified.

DESIGN

A survey among nursing home physicians.

SETTING & PARTICIPANTS

We sent a questionnaire to all (356) nursing homes in the Netherlands, to be completed by one of the physicians.

RESULTS

We received 245 completed questionnaires. As 21 institutions appeared to be closed or merged into other institutions, the response was 73.1% (245/335). Of all respondents 81.9% reported a vaccination rate above 80%. Almost 50% reported a vaccination rate above 90%. Most respondents considered herd immunity to be an important consideration for institutional policy. Freedom of choice for residents was considered important by almost all. Nevertheless, 106 out of 245 respondents follow a tacit consent procedure, according to which vaccination will be administered unless the resident or her proxy refuses. These institutions show significantly higher vaccination rates (p < 0.03).

CONCLUSIONS

In our discussion we focus on the question whether tacit consent procedures can be morally justifiable. Such procedures assume that vaccination is good for residents either as individuals or as a group. Even though this assumption may be true for most residents, there are good reasons for preferring express consent procedures.

Health behavior associated with influenza vaccination among healthcare workers in long-term-care facilities

OBJECTIVE

To investigate the health behavior associated with influenza vaccination among healthcare workers (HCWs) in long-term-care facilities.

DESIGN

A cross-sectional, self-administered survey of HCWs, augmented with focus groups to further examine attitudes toward influenza vaccination.

SETTING

Two long-term-care facilities participated in the survey. The focus groups were held at one of the two facilities.

PARTICIPANTS

All HCWs were invited to participate in the survey and all nonmanagerial staff members were invited to participate in the focus groups. The response rate for the survey was 58% (231 of 401).

RESULTS

Vaccinated HCWs had a more positive attitude toward influenza vaccination and a greater belief that the vaccine is effective. This was not accompanied by differences in vaccine knowledge or values of potential preventive outcomes. Nonvaccinated respondents were more likely to believe that other preventive measures, such as washing hands, taking vitamins and supplements, eating a nutritious diet, exercising, and taking homeopathic or naturopathic medications, were more effective than vaccination. Additional findings from the focus groups suggest that HCWs believe that the main purpose of influenza vaccination programs is to protect residents' health at the expense, potential harm, and burden of responsibility of the staff.

CONCLUSIONS

This study identifies challenges to and opportunities for improving vaccination rates among HCWs. A message that emphasizes the health benefits of vaccination to staff members, such as including vaccination as part of a staff "wellness" program, may improve the credibility of influenza immunization programs and coverage rates.