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RESEARCH:
Andrew C Hayward, Richard Harling, Sally Wetten, Anne M Johnson, Susan Munro, Julia Smedley, Shahed Murad, and John M Watson
Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial
BMJ 2006; 333: 1241 [Abstract] [Full text]
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Rapid Responses published:

[Read Rapid Response] First, do no harm- the vaccination of healthcare professionals
Jaykar R. Panchmatia   (19 December 2006)
[Read Rapid Response] Preventing influenza outbreaks in care homes
Shailendra Kapoor   (21 December 2006)
[Read Rapid Response] Increasing influenza immunization rates in care home staff
S Kapoor   (29 December 2006)

First, do no harm- the vaccination of healthcare professionals 19 December 2006
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Jaykar R. Panchmatia,
Specialist registrar in neurosurgery
King's College Hospital, Denmark Hill, London, SE5 9RS.

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Re: First, do no harm- the vaccination of healthcare professionals

Editor- As healthcare professionals we all have two fundamental roles to play regarding vaccine programmes.

Firstly, anti- vaccination advocates have questioned the safety of vaccines since the days of John Birch, Surgeon Extraordinary to the Prince of Wales in the early 19th century. As healthcare professionals we have a clear responsibility to counter such claims and discuss the undoubted benefits of vaccinations with our patients.

Secondly, although the origins of the dictum “First, do no harm” remain contentious, its position as one of the core principles of modern medicine is undisputed. Hayward et al have demonstrated that all healthcare professionals working with the vulnerable must ensure that they are vaccinated against infections such as influenza to ensure that they do not inadvertently harm their patients.

Competing interests: None declared
Preventing influenza outbreaks in care homes 21 December 2006
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Shailendra Kapoor,
Res. Physician
University of Illinois (UIC), Chicago, IL, USA - 60612

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Re: Preventing influenza outbreaks in care homes

The article “Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial ” by Hayward et al was highly informative and provided direct evidence that vaccinating nursing home staff against influenza can reduce influenza related morbidity and mortality in residents. However it needs to be remembered that vaccination of nursing staff alone is not effective in reducing influenza outbreaks in care facilities. A high rate of vaccination in both the staff as well as the elderly residents is necessary to successfully prevent such outbreaks (1).

Vaccination of nursing staff works by improving the herd immunity against influenza (2). Given the fact that the effectiveness of the influenza vaccine is only 23 % in the elderly (3) and 86 % in healthy younger adults (4) other preventive measures need to be strictly enforced in the case of an outbreak in a nursing home. These include (5):

• Implementation of droplet precautions for residents with suspected influenza

• Canceling group activities during outbreaks

• Use of antiviral medications such as amantidine if necessary

• Using separate staff for ill and healthy patients

• Cohorting of residents with influenza

• And education of nursing staff and residents on influenza

In the United States, the Centers for Medicare and Medicaid Services (CMS) requires that all care facilities annually offer mandatory influenza vaccination to their residents (unless refused or contra-indicated) as one of the conditions for participation in the medicare programme (6). Given the fact that the influenza vaccination rate in health workers is only about 38 % (7), similar mandatory implementation of vaccination in nursing staff is likely to go a long way in decreasing incidence of influenza in care homes.

Besides it needs to be remembered that annual influenza vaccination is highly recommended not only in the elderly but also in children 6 months to 2 years of age (8), pregnant women and individuals with diabetes mellitus, chronic renal failure, Human Immunodeficiency Virus (9) and chronic cardiovascular or pulmonary disorders (10).

1. Shugarman LR, Hales C, Setodji CM, Bardenheier B, Lynn J. The influence of staff and resident immunization rates on influenza-like illness outbreaks in nursing homes.J Am Med Dir Assoc. 2006 Nov;7(9):562- 7.

2. Patriarca PA, Weber JA, Parker RA, Orenstein WA, Hall WN, Kendal AP, et al. Risk factors for outbreaks of influenza in nursing homes. A case-control study. Am.J.Epidemiol. 1986 Jul;124(1):114-119.

3. Jefferson T, Rivetti D, Rivetti A, Rudin M, Di Pietrantonj C, Demicheli V. Efficacy and effectiveness of influenza vaccines in elderly people: a systematic review. Lancet 2005 Oct 1;366(9492):1165-1174.

4. Bridges CB, Thompson WW, Meltzer MI, Reeve GR, Talamonti WJ, Cox NJ, et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults: A randomized controlled trial. JAMA 2000 Oct 4;284(13):1655-1663.

5. Pearson ML, Bridges CB, Harper SA, Healthcare Infection Control Practices Advisory Committee (HICPAC), Advisory Committee on Immunization Practices (ACIP). Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2006 Feb 24;55(RR-2):1-16.

6. Centers for Medicare & Medicaid Services (CMS), HHS. Medicare and Medicaid programs; condition of participation: immunization standard for long term care facilities. Final rule. Fed.Regist. 2005 Oct 7;70(194):58833-58852.

7. King WD, Woolhandler SJ, Brown AF, Jiang L, Kevorkian K, Himmelstein DU, et al. Brief report: Influenza vaccination and health care workers in the United States. J.Gen.Intern.Med. 2006 Feb;21(2):181-184.

8. Griffin MR, Walker FJ, Iwane MK, Weinberg GA, Staat MA, Erdman DD, et al. Epidemiology of respiratory infections in young children: insights from the new vaccine surveillance network. Pediatr.Infect.Dis.J. 2004 Nov;23(11 Suppl):S188-92.

9. Skiest DJ, Machala T. Comparison of the effects of acute influenza infection and Influenza vaccination on HIV viral load and CD4 cell counts. J.Clin.Virol. 2003 Apr;26(3):307-315.

10. Baltimore RS, Jenson HB. New recommendations for influenza vaccination for children and pregnant women. Curr.Opin.Pediatr. 2003 Feb;15(1):74-76.

Competing interests: None declared
Increasing influenza immunization rates in care home staff 29 December 2006
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S Kapoor,
PGY2 Res. Physician
University of Illinois at Chicago, Chicago,IL- 60612

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Re: Increasing influenza immunization rates in care home staff

The article by Hayward et al (1) clearly showed that vaccinating care home staff against influenza can reduce deaths in residents. Besides decreasing morbidity and mortality in residents immunization of care home staff against influenza has numerous other benefits, including decreased absenteeism amongst care staff (2), decreased staffing problems (3) and decreased costs of hospitalization of residents and thus financial savings for the care home.(4)

Clearly efforts to increase immunization rates amongst health care workers have failed so far. New innovative measures need to be implemented urgently. Some measures that are more likely to succeed include:
A. Offering free vaccinations
B. Offering gift incentives.
C. Frequent in-services and presentations to increase awareness among health care workers about influenza. It has been shown that the fear of side effects is the most common reason health care workers refuse immunizations. The fear of acquiring influenza from the vaccine itself is the most often cited reason.(5)
D. Offering vaccinations in easily accessible areas such as the nursing home floors or cafeterias or setting up mobile “units” to administer vaccines.
E. Offering the vaccine at the same time as other mandatory tests such as annual tuberculosis screening has been shown to increase immunization rates.(6)

Mandatory vaccination is another consideration and should be given serious thought given the fact that voluntary immunization rates amongst health care staff are as low as 38 %.(7) Some of the US states such a Pennsylvania already require mandatory influenza vaccination for health care workers employed in long term care homes. Past experience has clearly shown that requiring mandatory vaccinations such as Hepatitis B for health care workers has clearly worked despite initial resistance. In fact in the near future mandatory annual influenza vaccination might be the final and definitive way to approach this problem.

1. Hayward AC, Harling R, Wetten S, Johnson AM, Munro S, Smedley J, et al. Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity, and health service use among residents: cluster randomised controlled trial. BMJ 2006; Dec 16;333(7581):1241.

2. Nichol KL, Lind A, Margolis KL, Murdoch M, McFadden R, Hauge M, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med 1995; Oct 5;333(14):889-93.

3. Canning HS, Phillips J, Allsup S. Health care worker beliefs about influenza vaccine and reasons for non-vaccination--a cross-sectional survey. J Clin Nurs 2005; Sep;14(8):922-5.

4. Boersma B, Rhames T, Keegan JM. Additional cost savings of an effective employee influenza program on prevention of nosocomial influenza. Am J Infect Control 1999; Apr;27(2):177-8.

5. Heininger U, Bachler M, Schaad UB. Attitudes of pediatricians regarding influenza self-immunization: a survey in a Swiss university children's hospital. Pediatr Infect Dis J 2003; May;22(5):391-4.

6. Steiner M, Vermeulen LC, Mullahy J, Hayney MS. Factors influencing decisions regarding influenza vaccination and treatment: a survey of healthcare workers. Infect Control Hosp Epidemiol 2002; Oct;23(10):625-7.

7. King WD, Woolhandler SJ, Brown AF, Jiang L, Kevorkian K, Himmelstein DU, et al. Brief report: Influenza vaccination and health care workers in the United States. J Gen Intern Med 2006; Feb;21(2):181-4.

Competing interests: None declared