Influenza control in acute care hospitals

Outbreaks in Health Care Settings

Outbreaks and pseudo-outbreaks in health care settings are complex and should be evaluated systematically using epidemiologic and molecular tools. Outbreaks result from failures of infection prevention practices, inadequate staffing, and undertrained or overcommitted health care personnel. Contaminated hands, equipment, supplies, water, ventilation systems, and environment may also contribute. Neonatal intensive care, endoscopy, oncology, and transplant units are areas at particular risk. Procedures, such as bronchoscopy and endoscopy, are sources of infection when cleaning and disinfection processes are inadequate. New types of equipment can be introduced and lead to contamination or equipment and medications can be contaminated at the manufacturing source.

Withdrawn: Vaccine hesitancy among Maltese Healthcare workers toward influenza and novel COVID-19 vaccination

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WITHDRAWN: Needed: less influenza vaccine hesitancy and less presenteeism among health care workers in the COVID-19 era

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Review of seasonal influenza vaccination in the Eastern Mediterranean Region: Policies, use and barriers

Vaccination is the main control measure for influenza and its severe complications. To better understand the influenza vaccination situation in the Eastern Mediterranean Region, we conducted an extensive review of literature published between 2006 and 2016 in the region on influenza vaccine policies, use, recommendations and coverage. Forty-eight articles met the inclusion criteria. These originated from 11 of the 22 countries of the region, with most being from Saudi Arabia and Iran. The review revealed knowledge gaps and misconceptions about influenza and its vaccines even among healthcare workers. Most of the papers reviewed reported low coverage in the target populations. Limited literature on the number of countries with concrete national influenza vaccination policies was available, which may not accurately represent the situation in the Region. In conclusion, lack of awareness and knowledge are the main barriers to influenza vaccination, which remains very low in the Eastern Mediterranean Region. Countries of the region need to promote and invest in research on influenza vaccination, which is critical to inform evidence-based programmes and policies to improve vaccination rates and control influenza.

Review of seasonal influenza vaccination in the Eastern Mediterranean Region: Policies, use and barriers

Vaccination is the main control measure for influenza and its severe complications. To better understand the influenza vaccination situation in the Eastern Mediterranean Region, we conducted an extensive review of literature published between 2006 and 2016 in the region on influenza vaccine policies, use, recommendations and coverage. Forty-eight articles met the inclusion criteria. These originated from 11 of the 22 countries of the region, with most being from Saudi Arabia and Iran. The review revealed knowledge gaps and misconceptions about influenza and its vaccines even among healthcare workers. Most of the papers reviewed reported low coverage in the target populations. Limited literature on the number of countries with concrete national influenza vaccination policies was available, which may not accurately represent the situation in the Region. In conclusion, lack of awareness and knowledge are the main barriers to influenza vaccination, which remains very low in the Eastern Mediterranean Region. Countries of the region need to promote and invest in research on influenza vaccination, which is critical to inform evidence-based programmes and policies to improve vaccination rates and control influenza.

Influenza Vaccination of Healthcare Workers in the United States, 1989-2002

Objectives.

We sought to estimate influenza vaccination coverage among healthcare workers (HCWs) in the United States during 1989-2002 and to identify factors associated with vaccination in this group. The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for HCWs to reduce transmission of influenza to patients at high risk for serious complications of influenza.

Design.

Analysis of cross-sectional data from 1989-2002 surveys conducted by the National Health Interview Survey (NHIS). The outcome measure was self-reported influenza vaccination in the past 12 months. Bivariate and multivariate analysis of 2002 NHIS data.

Setting.

Household interviews conducted during 1989-2002, weighted to reflect the noninstitutionalized, civilian US population.

Participants.

Adults aged 18 years or older participated in the study. A total of 2,089 were employed in healthcare occupations or settings in 2002, and 17,160 were employed in nonhealthcare occupations or settings.

Results.

The influenza vaccination rate among US HCWs increased from 10.0% in 1989 to 38.4% in 2002, with no significant change since 1997. In a multivariate model that included data from the 2002 NHIS, factors associated with a higher rate of influenza vaccination among HCWs aged 18-64 years included age of 50 years or older (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.1-2.1), hospital employee status (OR, 1.5; 95% CI, 1.2-1.9), 1 or more visits to the office of a healthcare professional in the past 12 months (OR, 1.5; 95% CI, 1.1-2.2), receipt of employer-provided health insurance (OR, 1.5; 95% CI, 1.1-2.1), a history of pneumococcal vaccination (OR, 3.9; 95% CI, 2.5-6.1), and history of hepatitis B vaccination (OR, 1.9; 95% CI, 1.4-2.4). Non-Hispanic black persons were less likely to be vaccinated (OR, 0.6; 95% CI, 0.5-0.9) than non-Hispanic white persons. There were no significant differences in vaccination levels according to HCW occupation category.

Conclusions.

Influenza immunization among HCWs reached a plateau during 1997-2002. New strategies are needed to encourage US HCWs to receive influenza vaccination to prevent influenza illness in themselves and transmission of influenza to vulnerable patients.

Preventing Nosocomial Influenza by Improving the Vaccine Acceptance Rate of Clinicians

Objectives:

To assess the effects of interventions to prevent transmission of influenza and to increase employee compliance with influenza vaccination.

Design:

The change in the proportion of hospitalized patients with laboratory-confirmed nosocomial influenza was observed over time and assessed using chi-square for trend analysis. The association between nosocomial influenza in patients and healthcare worker (HCW) compliance with vaccine was assessed by logistic regression.

Setting:

A 600-bed, tertiary-care academic hospital.

Methods:

After an outbreak of influenza A at this hospital in 1988, a mobile cart program was instituted with increased efforts to motivate employees to be vaccinated and furloughed when ill as well as new measures to prevent nosocomial spread.

Results:

HCW vaccination rates increased from 4% in 1987–1988 to 67% in 1999–2000 (P < .0001). Proportions of nosocomially acquired influenza cases among employees or patients both declined significantly (P < .0001). Logistic regression analysis revealed a significant inverse association between HCW compliance with vaccination and the rate of nosocomial influenza among patients (P < .001).

Conclusion:

A mobile cart vaccination program and an increased emphasis on HCWs to receive the vaccine were associated with a significant increase in vaccine acceptance and a significant decrease in the rate of nosocomial influenza among patients.

Attitudes and Practices Regarding Influenza Vaccination Among Healthcare Workers Providing Services to Individuals With Spinal Cord Injuries and Disorders

Objective:

To examine influenza vaccination status and predictors for vaccine receipt among healthcare workers (HCWs) caring for patients with spinal cord injuries and disorders.

Design:

Cross-sectional, nationwide anonymous survey.

Setting:

Twenty-three Veterans Affairs spinal cord injury centers.

Participants:

One thousand five hundred fifty-six HCWs.

Methods:

The primary outcome was staff vaccination status. Independent variables included staff demographic and employment characteristics, health status, attitudes and beliefs about the vaccine, and implications for its use.

Results:

The staff vaccination rate was 51%. Leading motivators of vaccine receipt were self-protection (77%) and patient protection (49%). The most common reasons for nonreceipt were concerns about side effects (49%), preventive quality (20%), and inconvenience (14%). Logistic regression results suggested that age of 50 years or older (OR, 1.47; P = .021), male gender (OR, 2.50; P < .001), strong belief in vaccine effectiveness (OR, 19.03; P = .008), and importance of HCW vaccination (OR, 20.50; P = .005) significantly increased the probability of vaccination. Recommending the vaccine to coworkers, patients, or patients' families was also associated with HCW vaccination (OR, 3.20; P < .001). Providers who did not believe the vaccine was protective (P < .001) or effective P < .001) were less likely to recommend it to patients.

Conclusions:

Strategies to increase vaccination rates among HCWs should address concerns about side effects, effectiveness, and protective value of the vaccine and access to it. The impact of provider recommendations should be stressed. Vaccination and subsequent prevention of illness may limit morbidity and mortality, thus benefiting HCWs, healthcare facilities, and patients.

Use of, Effectiveness of, and Attitudes Regarding Influenza Vaccine Among House Staff

Objective:

To determine influenza vaccination rates, vaccine effectiveness, and factors influencing vaccination decisions among house staff.

Design:

Cross-sectional survey.

Setting and Participants:

All residents registered at the University of Toronto were surveyed after the 1999-2000 influenza season. Of the 1,159 questionnaires mailed, 670 (58%) could be evaluated.

Results:

Influenza-like illnesses were reported by 36% of house staff. The vaccination rate was 51% among respondents, being highest for community and occupational medicine and pediatric staff (77% and 75%) and lowest for psychiatry, surgery, and radiology staff (32%, 36%, and 36%). Vaccinees reported significantly fewer episodes of illness (42 vs 54 per 100 subjects; P = .03) and fewer days of illness (272 vs 374 per 100 subjects; P = .02); absenteeism was not different (63 vs 69 per 100 subjects; P = .69). Self-protection was the most common reason for vaccination. Vaccinees believed the vaccine was more effective than did non-vaccinees (P < .01). Non-vaccinees considered influenza-like symptoms the most important side effect of the vaccine. Busy schedules and inconvenience were the most common reasons for not getting vaccinated. Overall, 44% of house staff believed the influenza vaccine should be mandatory.

Conclusions:

Influenza-like illness was common among house staff. They tended to work through their illnesses, potentially putting patients at risk. They were motivated mostly by self-protection and did report a benefit. Despite busy schedules and an unfounded fear of getting influenza symptoms from the vaccine, many thought the vaccine should be mandatory.

Mandatory influenza vaccination for health care workers as the new standard of care: a matter of patient safety and nonmaleficent practice

A growing body of literature defends the efficacy of seasonal influenza vaccination for health care workers in reducing the mortality of hospitalized patients. I review the evidence concerning influenza vaccination, concluding that universal vaccination of health care workers against influenza should be considered standard patient care and that nonvaccination represents maleficent care. I further argue that the ethical responsibility to ensure universal vaccination of staff against seasonal influenza lies not only with individual health care providers but with each individual health care institution.

Transcriptomic characterization of the novel avian-origin influenza A (H7N9) virus: specific host response and responses intermediate between avian (H5N1 and H7N7) and human (H3N2) viruses and implications for treatment options

A novel avian-origin H7N9 influenza A virus (IAV) emerged in China in 2013, causing mild to lethal human respiratory infections. H7N9 originated with multiple reassortment events between avian viruses and carries genetic markers of human adaptation. Determining whether H7N9 induces a host response closer to that with human or avian IAV is important in order to better characterize this emerging virus. Here we compared the human lung epithelial cell response to infection with A/Anhui/01/13 (H7N9) or highly pathogenic avian-origin H5N1, H7N7, or human seasonal H3N2 IAV. The transcriptomic response to H7N9 was highly specific to this strain but was more similar to the response to human H3N2 than to that to other avian IAVs. H7N9 and H3N2 both elicited responses related to eicosanoid signaling and chromatin modification, whereas H7N9 specifically induced genes regulating the cell cycle and transcription. Among avian IAVs, the response to H7N9 was closest to that elicited by H5N1 virus. Host responses common to H7N9 and the other avian viruses included the lack of induction of the antigen presentation pathway and reduced proinflammatory cytokine induction compared to that with H3N2. Repression of these responses could have an important impact on the immunogenicity and virulence of H7N9 in humans. Finally, using a genome-based drug repurposing approach, we identified several drugs predicted to regulate the host response to H7N9 that may act as potential antivirals, including several kinase inhibitors, as well as FDA-approved drugs, such as troglitazone and minocycline. Importantly, we validated that minocycline inhibited H7N9 replication in vitro, suggesting that our computational approach holds promise for identifying novel antivirals.

IMPORTANCE

Whether H7N9 will be the next pandemic influenza virus or will persist and sporadically infect humans from its avian reservoir, similar to H5N1, is not known yet. High-throughput profiling of the host response to infection allows rapid characterization of virus-host interactions and generates many hypotheses that will accelerate understanding and responsiveness to this potential threat. We show that the cellular response to H7N9 virus is closer to that induced by H3N2 than to that induced by H5N1, reflecting the potential of this new virus for adaptation to humans. Importantly, dissecting the host response to H7N9 may guide host-directed antiviral development.

Review: interventions to increase influenza vaccination among healthcare workers in hospitals

Please cite this paper as: Hollmeyer et al. (2012) Review: interventions to increase influenza vaccination among healthcare workers in hospitals. Influenza and Other Respiratory Viruses 7(4), 604–621.

Annual influenza vaccination rates among hospital healthcare workers (HCW) are almost universally low despite recommendations from WHO and public health authorities in many countries. To assist in the development of successful vaccination programmes, we reviewed studies where interventions aimed to increase the uptake of influenza vaccination among hospital HCW. We searched PUBMED from 1990 up to December 2011 for publications with predetermined search strategies and of pre‐defined criteria for inclusion or exclusion. We evaluated a large number of ‘intervention programmes’ each employing one or more ‘intervention components’ or strategies, such as easy access to vaccine or educational activities, with the goal to raise influenza vaccine uptake rates in hospital HCW during one influenza season. Included studies reported results of intervention programmes and compared the uptake with the season prior to the intervention (historical control) or to another intervention programme within the same season that started from the same set of baseline activities. Twenty‐five studies performed in eight countries met our selection criteria and described 45 distinct intervention programmes. Most studies used their own facility as historical control and evaluated only one season. The following elements were used in intervention programmes that increased vaccine uptake: provision of free vaccine, easy access to the vaccine (e.g. through mobile carts or on‐site vaccination), knowledge and behaviour modification through educational activities and/or reminders and/or incentives, management or organizational changes, such as the assignment of personnel dedicated to the intervention programme, long‐term implementation of the strategy, requiring active declination and mandatory immunization policies. The number of these components applied appeared to be proportional to the increase in uptake. If influenza uptake in hospital HCW is to be increased on sustained basis, hospital managers need to be committed to conduct a well‐designed long‐term intervention programme that includes a variety of co‐ordinated managerial and organizational elements.

Evaluation of 2009 pandemic influenza A (H1N1) exposures and illness among physicians in training

BACKGROUND

A cluster of influenza-like illness (ILI) among physicians in training during the 2009 influenza A (H1N1) pandemic (pH1N1) led to a health hazard evaluation.

METHODS

We conducted a cross-sectional study to examine exposures, infection control practices, ILI prevalence, and transmission among physicians in training at 4 affiliated hospitals during the pandemic. We administered an electronic survey and met with physicians in training and hospital personnel.

RESULTS

Of the 88 responding physicians, 85% reported exposure to pH1N1. Exposures occurred at work from patients or coworkers and outside of work from coworkers, household members, or the community. Thirteen cases of ILI were reported in May-June 2009; 10 respondents reported working while ill (duration, 1-4 days). Between 13% and 88% of respondents knew which personal protective equipment (PPE) was recommended when caring for influenza patients at the 4 hospitals. The most common reasons for not using PPE were not knowing that a patient had pH1N1 or ILI and not having PPE readily available.

CONCLUSIONS

Physicians in training have gaps in their knowledge of and adherence to recommended PPE and compliance with work restrictions. Our findings underscore the importance of installing isolation precaution signage, making PPE readily available near patients with influenza, and facilitating work restrictions for ill health care personnel.

Large epidemiological influenza a outbreak in a teaching hospital from guatemala city

Objective. To describe the characteristics and interventions to control a large epidemiological Influenza A Outbreak. Methods. During the months of February to April 2006, a large outbreak of Influenza A was detected, which affected Health Care Workers and hospitalized patients in a large teaching Hospital in Guatemala City. Interventions to interrupt transmission were implemented and included barrier methods (N95 masks, respiratory isolation measures, etc.) and enhanced hand hygiene, vaccination of healthy Health Care Workers (HCW), restrictions for patient visits. Results. From February to April 2006, 59 hospitalized patients diagnosed with Influenza A. 19 AIDS patients (mortality: 71%) and 5/40 (12.5%) in other diseases: cancer (3), severe cardiac failure (1) and severe malnutrition (1). The attack rate at day 20 in doctors and medical students was 21% while in other HCW it was 10.5%. Within 3 weeks of the beginning of the plan, deaths were stopped and no more cases in HCW were detected after 3 additional weeks. Conclusion. A rapid, comprehensive plan for the control of nosocomial epidemic Influenza A outbreaks is essential to limit severe morbidity and mortality in hospitals who attend large immunocompromised populations, including AIDS patients. HCW regular vaccinations programs are mandatory.

Nosocomial Influenza in a Pediatric Hospital: Comparison of Rates of Seasonal and Pandemic 2009 Influenza A/H1N1 Infection

The rates of nosocomial seasonal (January 2008 to March 2009) and 2009 A/H1N1 (April 2009 to December 2010) influenza infections in a children's hospital were compared. Droplet precautions were used. The rates were similar during both periods, suggesting that use of droplet precautions did not result in a higher rate of influenza A/H1N1 infection.

Infect Control Hosp Epidemiol2012;33(3):292-294

Nosocomial influenza in a pediatric hospital: comparison of rates of seasonal and pandemic 2009 influenza A/H1N1 infection

The rates of nosocomial seasonal (January 2008 to March 2009) and 2009 A/H1N1 (April 2009 to December 2010) influenza infections in a children's hospital were compared. Droplet precautions were used. The rates were similar during both periods, suggesting that use of droplet precautions did not result in a higher rate of influenza A/H1N1 infection.

Transmission of pandemic (H1N1) 2009 influenza to healthcare personnel in the United States

After identification of pandemic 2009 influenza (pH1N1) in the United States, the Centers for Disease Control and Prevention (CDC) worked with state and local health officials to characterize infections among healthcare personnel (HCP). Detailed information, including likely routes of exposure, was reported for 70 HCP from 22 states. Thirty-five cases (50%) were classified as being infected in healthcare settings, 18 cases (26%) were considered to have been infected in community settings, and no definitive source was identified for 17 cases (24%). Of the 23 HCP infected by ill patients, only 20% reported using an N95 respirator or surgical mask during all encounters and more than half worked in outpatient clinics. In addition to community transmission, likely patient-to-HCP and HCP-to-HCP transmission were identified in healthcare settings, highlighting the need for comprehensive infection control strategies including administration of influenza vaccine, appropriate management of ill HCP, and adherence to infection control precautions.

Assessing physicians' in training attitudes and behaviors during the 2009 H1N1 influenza season: a cross-sectional survey of medical students and residents in an urban academic setting

Please cite this paper as: May et al. (2010) Assessing physicians’ in training attitudes and behaviors during the 2010 H1N1 influenza season: a cross‐sectional survey of medical students and residents in an urban academic setting. Influenza and Other Respiratory Viruses DOI: 10.1111/j.1750‐2659.2010.00151.x.

Background  Despite concern for hospital‐based transmission of influenza, little research has been carried out on perceptions and behaviors of physicians in training with regard to influenza‐like illness (ILI), especially in light of the recent H1N1 pandemic.

Objectives  We aimed to evaluate self‐reported episodes of ILI among medical students and residents to determine the impact of ILI on school and clinical performance, absenteeism, and patterns of preventive measures used by this population both in and out of the healthcare setting.

Methods  We anonymously surveyed medical students and residents at an urban institution between November 3 and December 11, 2009. Data were analyzed separately for medical students and residents for frequency of close‐ended responses. Open‐ended answers were analyzed thematically. Our Institutional Review Board exempted this study from review.

Results  Forty‐five percent of medical students and 53% of resident respondents perceived the risk of acquiring H1N1 at school or work as high, and although 43% of medical students and 66% of resident respondents had received the influenza vaccination and most reported increasing non‐pharmaceutical preventive measures, 9% of medical students and 61% of residents with one or more episodes of ILI chose to continue to attend class or work when ill.

Conclusions  Although students and residents report high risk of infection because of work‐ or school‐related activities, many involved in patient care activities do not comply with recommended infection control precautions. Educational campaigns should be developed and infection control guidelines should be included in routine medical student and resident curricular activities.

Prioritizing healthcare worker vaccinations on the basis of social network analysis

OBJECTIVE

To use social network analysis to design more effective strategies for vaccinating healthcare workers against influenza.

DESIGN

An agent-based simulation.

SETTING

A simulation based on a 700-bed hospital.

METHODS

We first observed human contacts (defined as approach within approximately 0.9 m) performed by 15 categories of healthcare workers (eg, floor nurses, intensive care unit nurses, staff physicians, phlebotomists, and respiratory therapists). We then constructed a series of contact graphs to represent the social network of the hospital and used these graphs to run agent-based simulations to model the spread of influenza. A targeted vaccination strategy that preferentially vaccinated more "connected" healthcare workers was compared with other vaccination strategies during simulations with various base vaccination rates, vaccine effectiveness, probability of transmission, duration of infection, and patient length of stay.

RESULTS

We recorded 6,654 contacts by 148 workers during 606 hours of observations from January through December 2006. Unit clerks, X-ray technicians, residents and fellows, transporters, and physical and occupational therapists had the most contacts. When repeated contacts with the same individual were excluded, transporters, unit clerks, X-ray technicians, physical and occupational therapists, and social workers had the most contacts. Preferentially vaccinating healthcare workers in more connected job categories yielded a substantially lower attack rate and fewer infections than a random vaccination strategy for all simulation parameters.

CONCLUSIONS

Social network models can be used to derive more effective vaccination policies, which are crucial during vaccine shortages or in facilities with low vaccination rates. Local vaccination priorities can be determined in any healthcare facility with only a modest investment in collection of observational data on different types of healthcare workers. Our findings and methods (ie, social network analysis and computational simulation) have implications for the design of effective interventions to control a broad range of healthcare-associated infections.

Seasonal influenza risk in hospital healthcare workers is more strongly associated with household than occupational exposures: results from a prospective cohort study in Berlin, Germany, 2006/07

BACKGROUND

Influenza immunisation for healthcare workers is encouraged to protect their often vulnerable patients but also due to a perceived higher risk for influenza. We aimed to compare the risk of influenza infection in healthcare workers in acute hospital care with that in non-healthcare workers over the same season.

METHODS

We conducted a prospective, multicentre cohort study during the 2006/07 influenza season in Berlin, Germany. Recruited participants gave serum samples before and after the season, and completed questionnaires to determine their relevant exposures and possible confounding factors. The main outcome measure was serologically confirmed influenza infection (SCII), defined as a fourfold or greater rise in haemagglutination inhibition antibody titres to a circulating strain of influenza (with post-season titre at least 1:40).Weekly mobile phone text messages were used to prompt participants to report respiratory illnesses during the influenza season. A logistic regression model was used to assess the influence of potential risk factors.

RESULTS

We recruited 250 hospital healthcare workers (mean age 35.7 years) and 486 non-healthcare workers (mean age 39.2 years) from administrative centres, blood donors and colleges.Overall SCII attack rate was 10.6%. Being a healthcare worker was not a risk factor for SCII (relative risk 1.1, p = 0.70). The final multivariate model had three significant factors: living with children (odds ratio [OR] 3.7, p = 0.005), immunization (OR 0.50, p = 0.02), and--among persons living in households without children--ownership of a car (OR 3.0, p = 0.02). Living with three or more children (OR 13.8, p < 0.01) was a greater risk than living with one or two children (OR 5.3, p = 0.02). 30% of participants with SCII reported no respiratory illness. Healthcare workers were at slightly higher risk of reporting any respiratory infection than controls (adjusted OR 1.3, p = 0.04, n = 850).

CONCLUSIONS

Our results suggest that healthcare workers in hospitals do not have a higher risk of influenza than non-healthcare workers, although their risk of any respiratory infection is slightly raised. Household contacts seem to be more important than exposure to patients. Car ownership is a surprise finding which needs further exploration. Asymptomatic infections are common, accounting for around a third of serologically confirmed infections.

Self-reported influenza vaccination rates among health care workers in a large health system

BACKGROUND

The national health care worker (HCW) influenza vaccination rate is only 42% despite recommendations that HCWs receive influenza vaccine to prevent influenza among patients.

METHODS

Following an educational intervention to improve influenza vaccination in 6 facilities in a large health system (University of Pittsburgh Medical Center), surveys were mailed to 1200 nonphysician HCWs to determine factors related to influenza vaccination and inform the following year's intervention. HCWs were proportionally sampled with oversampling for minority HCWs, and analyses were weighted to adjust for the clustered nature of the data.

RESULTS

Response rate was 61%. Influenza vaccination rates were 77% overall, 65% for minority HCWs and 80% for white HCWs (P = .02) for ever receiving vaccine; and 57% overall, 45% for minority HCWs and 60% for white HCWs (P = .009) for receiving vaccine in 2005-2006. In logistic regression, belief that getting vaccinated against influenza is wise, physician recommendation, and older age were associated with higher likelihood of vaccination, whereas minority race and good health were associated with lower likelihood of ever receiving influenza vaccine.

CONCLUSION

To increase influenza vaccination, interventions should address HCWs' most important reasons for getting vaccinated: convenience and protecting themselves from influenza.

Working with symptoms of a respiratory infection: staff who care for high-risk individuals

BACKGROUND

While many health care workers (HCWs) who have respiratory infections take sick leave, others work following illness onset. Little is known about attendance practices of HCWs caring for persons with spinal cord injuries (SCI), a group at high risk for respiratory complications.

METHODS

Cross-sectional survey of HCWs. Logistic regression identified factors associated with having a respiratory infection and examined if awareness of facility level institutional control measures and/or individual level factors influenced working while symptomatic.

RESULTS

Response rate was 53% (n = 820). Respiratory infections were reported by 36%; of those, 86% attended work while symptomatic. HCWs aged 50 and above were less likely (odds ratio [OR] 0.58, P = 0.003) and those with a chronic condition were more likely (OR 2.24, P < 0.000) to have had a respiratory infection. HCWs who indicated that their facility institutes droplet precautions (OR 0.42, P = 0.034), restricts staff movement between wards, (OR 0.26, P = 0.002), and restricts contact between patients (OR 0.32, P = 0.009) were significantly less likely to work while symptomatic.

CONCLUSIONS

It is alarming that 86% of HCWs attended work while symptomatic, given the consequences that respiratory infection can have on persons with SCI. HCW awareness of outbreak control measures within their facilities appeared to influence their attendance decisions, suggesting the importance of policy placement and information dissemination.

Influenza and rhinovirus infections among health-care workers

BACKGROUND AND OBJECTIVE

Health-care workers (HCWs) are at higher risk of acquisition and transmission of respiratory virus infections. Nosocomial transmission of influenza has been documented but whether this is so for other respiratory viruses has not been assessed.

METHODS

Epidemiological, clinical and viral laboratory surveillance was carried out on HCWs presenting with acute respiratory infection in a university hospital.

RESULTS

Over a 2-year period, 203 subjects were recruited: rhinovirus was the most frequently detected virus (37.7% in flu negative samples) and influenza A/B was positive in only 12.3% of subjects. Only 19.7% of HCWs were immunized against influenza. High detection of rhinovirus occurred even during the peak of the influenza season and half of the infected subjects reported an influenza-like illness.

CONCLUSION

Rhinovirus infection occurred frequently in this study population and probably contributes to influenza misdiagnosis. Educational interventions about different viruses causing respiratory symptoms and an increase in standards of infection control besides influenza immunization among HCWs is needed.

Improving influenza immunization rates among healthcare workers caring for high-risk pediatric patients

OBJECTIVE

To assess influenza vaccination rates of healthcare workers (HCWs) in neonatal intensive care units (NICUs), pediatric intensive care units (PICUs), and oncology units in Pediatric Prevention Network (PPN) hospitals.

PARTICIPANTS

Infection control practitioners and HCWs in NICUs, PICUs, and oncology units.

METHODS

In November 2000, posters, electronic copies of a slide presentation, and an influenza fact sheet were distributed to 32 of 76 PPN hospitals. In January 2001, a survey was distributed to PPN hospital participants to obtain information about the immunization campaigns. On February 7, 2001, a survey of influenza immunization was conducted among HCWs in NICU, PICU, and oncology units at participating hospitals.

RESULTS

Infection control practitioners from 19 (25%) of the 76 PPN hospitals completed the surveys. The median influenza immunization rate was 43% (range, 12% to 63%), with 7 hospitals exceeding 50%. HCWs (n = 1123) at 15 PPN hospitals completed a survey; 53% of HCWs reported receiving influenza immunization. Immunization rates varied by work site: 52% in NICUs and PICUs compared with 60% in oncology units. Mobile carts and PPN educational fact cards were associated with higher rates among these subpopulations (P < .001) (361 [63%] of 575 vs 236 [44%] of 541 for mobile carts; 378 [60%] of 633 vs 219 [45%] of 483 for fact cards).

CONCLUSION

Despite delayed distribution of influenza vaccine during the 2000-2001 season, immunization rates at 7 hospitals and among HCWs in high-risk units exceeded the National Association of Children's Hospitals and Related Institutions goal of 50%.

Respiratory Viruses and Severe Lower Respiratory Tract Complications in Hospitalized Patients

BACKGROUND

Acute respiratory viral infections are generally self-limited in healthy subjects but can lead to severe complications in immunocompromised hosts. We report the clinical impact of acute lower respiratory tract viral infections in hospitalized patients.

MATERIALS AND METHODS

Of 1,001 fiberoptic bronchoscopies performed during a period of 5 years, 33 BAL samples were positive for respiratory viruses by cell culture. The main diagnosis, length of hospitalization, response to initial treatment, and the mortality rate at 30 days were analyzed. Spirometry performed before and after infection was compared in lung transplant recipients.

RESULTS

The following respiratory viruses were identified in 33 cases: influenza A or B (n = 13), parainfluenza virus 1-3 (n = 7), rhinovirus (n = 5), respiratory syncytial virus (n = 4), and adenovirus (n = 4). All cases were immunocompromised patients who acquired new respiratory symptoms and/or radiologic abnormalities suggesting a pulmonary infection. Twenty-five patients (74%) did not respond to initial broad-spectrum antibiotics, and 11 patients (33%) required intensive care for respiratory failure. The overall mortality rate at 1 month was 24%. In patients with a sole viral pathogen identified in their BAL, the mortality rate was 39%. In lung transplant recipients (n = 10), the mean FEV(1) decreased from 2.2 to 1.9 L/s before and during the infection episode, respectively (p < 0.01); 3 months later, 60% of the patients had still not completely recovered to baseline values.

CONCLUSION

Respiratory viruses recovered in BAL samples of immunocompromised patients are associated with severe lower respiratory complications. In lung transplant recipients, we observed a persisting impairment of pulmonary function.

Nosocomial influenza in children

Influenza is the most important cause of acute respiratory illness leading to hospitalization among children during community epidemics. This illness can cause extensive nosocomial outbreaks with serious morbidity and mortality among specific groups of children. Paediatric patients with community-acquired influenza and healthcare workers are the main reservoir for the nosocomial spread of the virus. During epidemics in the community, testing for influenza should be requested in all children with compatible symptoms admitted in the hospital, and measures should be introduced for the prevention or early control of an outbreak. Recent advances in the management of influenza include rapid diagnoses based on antigen detection and the identification of the new neuraminidase inhibitors zanamivir and oseltamivir. Annual vaccination against influenza of children with high-risk conditions, their family members and healthcare workers is the principle measure for the prevention of nosocomial outbreaks. Although vaccination against influenza appears to be cost-effective at all ages in terms of prevention of illness, related hospitalizations, deaths, reduction of healthcare costs and productivity loss, vaccination coverage among target groups is limited.

Transmission of influenza: implications for control in health care settings

Annual influenza epidemics in the United States result in an average of >36,000 deaths and 114,000 hospitalizations. Influenza can spread rapidly to patients and health care personnel in health care settings after influenza is introduced by visitors, staff, or patients. Influenza outbreaks in health care facilities can have potentially devastating consequences, particularly for immunocompromised persons. Although vaccination of health care personnel and patients is the primary means to prevent and control outbreaks of influenza in health care settings, antiviral influenza medications and isolation precautions are important adjuncts. Although droplet transmission is thought to be the primary mode of influenza transmission, limited evidence is available to support the relative clinical importance of contact, droplet, and droplet nuclei (airborne) transmission of influenza. In this article, the results of studies on the modes of influenza transmission and their relevant isolation precautions are reviewed.

Nosocomial influenza at a Canadian pediatric hospital from 1995 to 1999: opportunities for prevention

Nineteen cases of nosocomial influenza occurred at a pediatric hospital during a 5-year period. Only one of the nine children with chronic health conditions had been immunized. Length of stay was prolonged for seven children, with three intensive care unit admissions. We have now implemented strategies to decrease nosocomial influenza infection.

Disruption of services in an internal medicine unit due to a nosocomial influenza outbreak

OBJECTIVE

To describe a nosocomial influenza A outbreak, how it was managed, what impact it had on subsequent delivery of health care, and the additional charges attributable to it

DESIGN

Prospective cohort study and microbiological investigation.

SETTING

One internal medicine unit in an acute care, university-affiliated hospital.

PARTICIPANTS

Twenty-three patients and 22 staff members from February 28 to March 6, 1999.

RESULTS

Attack rates were 41% (9 of 22) among patients and 23% (5 of 22) among staff members, with 3 of 14 cases being classified as "certain." The influenza virus isolates were typed as A/SYDNEY/5/97 (H3N2). The index case was a patient who shared a room with the first nosocomial case. Vaccination rates for influenza virus were 43% (10 of 23) among patients and 36% (8 of 22) among staff members. The outbreak resulted in staff members' taking 14 person-days of sick leave. Furthermore, 8 scheduled admissions were postponed and all emergency admissions were suspended for 11 days. Hospital charges attributable to the influenza outbreak totaled $34,179 and the average extra charge per infected patient was $3,798.

CONCLUSIONS

Nosocomial influenza outbreaks increase charges and alter the quality of care delivered in acute care settings. Strategies for their prevention need to be evaluated in acute care settings.

Clinical features of influenza A virus infection in older hospitalized persons

OBJECTIVES

To determine the value of clinical parameters in predicting influenza in older persons and those with underlying cardiopulmonary conditions hospitalized with respiratory illnesses.

DESIGN

Prospective evaluation of hospitalized persons from November 15, 1999, to April 15, 2000.

SETTING

A 450-bed general medical-surgical hospital in Rochester, New York.

PARTICIPANTS

Patients aged 65 and older or those with underlying cardiopulmonary conditions admitted to the hospital with respiratory diagnoses.

MEASUREMENTS

The ability to discriminate influenza from noninfluenza cases using clinical parameters. Influenza infection was documented by culture, rapid antigen detection, reverse transcription-polymerase chain reaction, or serology.

RESULTS

Sixty-one influenza A infections (mean age +/- standard deviation = 79 +/- 10) were identified in 332 evaluated illnesses (18.3%). Fifty-six cases occurred in 168 patients (33%) during a 9-week epidemic period; 40 were considered contagious on the basis of a positive culture or antigen test. Neither single clinical parameters nor logistic regression analysis using all parameters clearly discriminated influenza from noninfluenza cases. The complex of cough, temperature of 38 degrees C or higher, and illness duration of 7 days or less provided the best discrimination between infected and uninfected subjects; during the epidemic period, 53% of subjects with this symptom complex had influenza, compared with 18% without these symptoms (relative risk = 2.99, 95% confidence interval = 1.85-4.83). This symptom complex had a sensitivity of 78% and a specificity of 73% for contagious influenza during the epidemic period.

CONCLUSIONS

In older persons and those with underlying cardiopulmonary conditions admitted with acute respiratory illness during influenza epidemics, the presence of fever, cough, and brief illness should be useful for institution of respiratory isolation and for design of antiviral trials.

Outbreaks of influenza A virus infection in neonatal intensive care units

BACKGROUND

Outbreaks of nosocomial influenza virus infections have been described rarely during childhood and even less so in the neonatal period.

METHODS

We report 30 neonates admitted to 2 neonatal intensive care units with nosocomial influenza A virus infection, which occurred in 2 outbreaks during 1999. Risk factors for infection were evaluated, and control measures were adopted. Virus was detected by indirect immunofluorescence antibody screen. Any infant with nasopharyngeal aspirate positive for influenza A virus was considered infected.

RESULTS

Of 95 infants screened 30 were positive for influenza A virus (31.5%). Mean birth weight was 1622 g, and mean gestational age was 31 weeks in the infected group. In the noninfected group mean birth weight was 2594 g and mean gestational age was 36.4 weeks. Low birth weight, short gestational age, twin pregnancy and mechanical ventilation were identified as risk factors for infection. Clinical symptoms were seen in 22, and 8 were asymptomatic. Clinical features were predominantly respiratory and digestive. The outcome was favorable in all cases.

CONCLUSIONS

Infection by influenza virus has to be considered as a possible cause of nosocomial infection in the neonatal period. Control measures and prevention are important.

Current paradoxes and changing paradigms in vaccinology

Other than the provision of clean water, food and sanitation, no other deliberate human intervention has prolonged the human life span as much as the provision of vaccines and the control of infectious disease. Since 1950, 25 vaccines have been licensed in the US, 15 of these for routine universal use in the population. On the horizon are vaccines not only to prevent infectious diseases, but also vaccines against cancer and a host of other human ills. Despite these public health and scientific accomplishments however, the manner in which we think about, develop and apply vaccines to the public health has common heuristic flaws which prevent realizing the full benefits of vaccines to society. This paper will discuss a number of current paradoxes and changing paradigms related to the field of vaccinology.