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 doi: https://doi.org/10.1136/bmj.39010.581354.55 (Published 14 December 2006) Cite this as: BMJ 2006;333:1241
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests