Mandatory Flu Vaccine for Health-Care Workers? It’s About Time

As former British Prime Minister Margaret Thatcher recovers from a bout of the flu in London’s private Cromwell Hospital, I’m reminded that it’s time to trek over to infection control at my hospital and stick my arm out for a flu shot. Ms. Thatcher is assuredly receiving the best care available, and I hope that part of that care includes flu vaccinations for her attending doctors and nurses.

I’m not sure about the statistics in the U.K., but in the United States, only about 40 percent of health-care personnel get vaccinated against the flu each year. When health-care workers skip their flu vaccines, they are jeopardizing their patients’ well being – who, like Ms. Thatcher, are likely to be at risk of complications – including death – from a flu infection. According to Ms. Thatcher’s spokesperson, she was hospitalized on October 19^th for tests after failing to recover from a bout of the flu. She had missed her 85^th birthday party on October 14, because of the flu. As of Sunday, October 24, she appears to be recovering but will spend a few more days in the hospital.

Since at least 2006 , the Centers for Disease Control (CDC) has recommended that all health-care workers receive flu vaccines. Yet those recommendations have had little effect. Flu vaccination rates among health-care personnel remain at about 40 percent, while a rate of at least 80 percent is required for herd immunity. But in a policy statement published in October 2010, the American Academy of Pediatrics (AAP) upped the ante for health-care personnel by recommending that influenza vaccination be mandatory for all health-care workers and ancillary personnel:

Mandatory programs for all HCP should be implemented nationwide. Mandating influenza vaccine for all HCP is ethically justified, necessary, and long overdue. Employees of health care institutions have both ethical and professional obligations to act in the best interests of the health of their patients.

While the word “mandate” is always good for a fight, the AAP hit the nail on the head with this one. Mandate? You bet. Health-care provider have an ethical and moral responsibility to their patients. Remember “do no harm?” Harm can be done actively – prescribing a wrong medication or treatment – or passively – inadvertently infecting that neonate with the flu.

Influenza is the most deadly vaccine-preventable disease in the United States. Each year during the 1990s, 36,000 people died from influenza and its complications, and more than 200,000 were hospitalized. The most vulnerable were children aged 65 and older and children younger than five years, as well as people with chronic medical conditions such as asthma. Anyone working in a health-care setting (say, the cook in a hospital or nursing home, or the janitor in a birthing center) has a responsibility to protect the people we serve.

As supervisor of a small emergency medical service, I fight this fight have every year with my personnel. And when I ask them why they’re so resistant to receiving the flu vaccine, I hear them recite the same myths about flu vaccine that abound in the general public.

Here are some of those myths, and the truths that bust them:

• Myth 1: “Every time I get the flu shot, I get the flu.” I even heard this one from an accomplished and experienced nurse practitioner who insisted that she “got the flu” after receiving the H1N1 vaccine last year.
  • Truth 1.1: Fewer than one percent of people who are vaccinated with the injectable vaccine develop flu-like symptoms, such as mild fever and muscle aches, after vaccination. These side effects are not the same as having influenza, but people confuse the symptoms.
  • Truth 1.2: After you’re vaccinated, protective immunity doesn’t develop until 1-2 weeks later. People who are exposed to the flu virus during this 1-2 week immune response time may get influenza. This is most common among people who receive the vaccine late in the season (December or later).
  • Truth 1.3: All viral illnesses that involve fever, sore throat, snotty nose, and cough are not created equal. Many people – even health-care workers – perceive any illness with these symptoms as “the flu.” People who become infected with other viruses may blame it on the flu shot or think they got “the flu” despite being vaccinated.
• Myth 2: “You can still get sick if you get the flu shot, so why bother?”
  • Truth 2.1: Yes, you can still develop flu after you receive the flu shot. But healthy young adults appear to receive most benefits. According to the Immunization Action Coalition, the vaccine is “effective in protecting 90 percent of healthy young adults from illness when the vaccine strain is similar to the circulating strain.” Health-care workers have an obligation to protect their patients – who are often frail and more susceptible to the flu and its effects. People who have been vaccinated are likely to be less contagious (i.e. shed less virus) for a shorter time if they do become infected.
  • Truth 2.2: Older persons, especially, may not be 100 percent protected against influenza. Only 30-40 percent of frail elderly persons will not become ill from the flu at all. But the vaccine dramatically lessens the severity of illness in this population – in lifesaving ways. Again, from the Immunization Action Coalition: “Among elderly persons, the vaccine is 20%-70% effective in preventing hospitalization and 80% effective in preventing death.”
• Myth 3: “You can’t get the flu vaccine if you’re allergic to eggs.”
  • Truth 3: Historically, people with egg allergies were advised not to get vaccinated against the flu because the vaccine contains egg protein and could potentially trigger an allergic reaction. However, studies conducted in the wake of the H1N1 pandemic have shown that the tiny amounts of egg protein in flu vaccines, not enough to trigger a reaction in the majority of people with egg allergies. Based on these findings, in October 2010 the American Academy of Allergy, Asthma, & Immunology published new recommendations regarding the use of flu vaccine in people with egg allergies. According to the new recommendations, most people with egg allergies can safely receive the flu vaccine safely under the care of their allergist/immunologist.
• Myth 4: I never get sick, and if I do, I recover quickly. I don’t need to be vaccinated.”
  • Truth 4.1: Never say never. Last year’s H1N1 flu strain killed strong, healthy adolescents and adults –
  • Truth 4.2: You may be able to recover fully from the flu, but that doesn’t mean that the people you infect will be. For health-care workers, especially those working in nursing homes or pregnant women, infants, and young children, the risk of passing on an infection that could turn deadly is especially high. According to the CDC, higher vaccination rates among health-care workers can reduce influenza-like illness, and even deaths, in settings like nursing homes.
• Myth 5: The flu vaccine isn’t safe.
  • Truth 5.1 Data confirming the safety of the flu vaccine are accumulating. The CDC issued new guidelines for use of the vaccine last August, recommending that nearly everyone aged 6 months and older receive the vaccination. Those recommendations are based on the vaccine’s long safety record – and clear demonstration that the risk of getting the flu is much greater than any risk associated with the vaccine.
  • Truth 5.2. About one in one million vaccinations have been associated with Guillain Barr syndrome. But that’s an association, not a proven causal link. In Guillain Barr Syndrome, a person’s immune system attacks nerve cells, leading to muscle weakness and sometimes paralysis. Symptoms usually last for a few weeks; rarely, people have permanent nerve damage. Even more rarely, people have died as a result of Guillain Barr Syndrome, usually from difficulty breathing. About 3,000 to 6,000 people develop Guillian Barr Syndrome in the United States each year, , for example, an estimated 3,000 to 6,000 people develop Guillain Barr Syndrome each year on average, whether or not they received a vaccination. In about two-thirds of cases, a respiratory illness or diarrhea prefaces the illness. Having the flu is itself a risk factor for the disease.
• Myth 6: I was vaccinated last year. That should be enough.
  • Truth 6.1: Influenza viruses, especially influenza type A viruses, are known for being unpredictable. They change constantly. That’s why there’s a new flu vaccine every year – and why you need to get it
  • Truth 6.2: The 2009 H1N1 strain appears to have made its way around the globe sufficiently that most people’s immune systems have at least a passing acquaintance with it. But that doesn’t mean we’re not still vulnerable to another pandemic. Remember “bird flu,” H5N1? It’s still out there percolating and infecting the occasional unfortunate poultry worker. And if a new strain appears and jumps species, current flu shots are not likely to confer any immunity.

In short, if you’re a health-care worker of any sort, whether you perform direct patient care or ancillary tasks such as housekeeping, transportation, or cooking, it’s time to stick out your arm. Ask your employer for that flu vaccine, and thank them if they’ve already provided it. If you’re a patient, ask your health-care provider and staff if they’ve had their flu shots. It’s only fair to you and your loved ones.