Do you or don’t you?

The 2013 influenza season is upon us in the southern hemisphere, and with it, health care workers are faced with the decision about whether or not to receive the seasonal influenza vaccination. For many, the decision to get vaccinated is ‘a given’ as they rationalise it is part of their professional obligation to keep themselves fit for work; as well as to protect their patients. This rationalisation is shared and recommended by the World Health Organisation (WHO)1. Others view getting vaccinated as unnecessary and too fraught with doubts to be considered a viable option to boost their immunity.

Despite slight increases in the flu vaccination uptakes rates by the New Zealand health workforce in the last three years, actual immunisation numbers remain low. The Ministry of Health’s 2012 (MOH) data revealed that only 48 per cent of District Health Board health care workers were vaccinated for influenza and the figure was lower again for DHB nurses at 46 per cent (6). Virologist and National Influenza Specialist Group spokesman Lance Jennings said this year that nurse vaccination levels still needed to improve and the Canterbury District Health Board had showed higher uptake was possible with 60 per cent of its nurses and 75 per cent of its midwives immunised, which was ‘much closer’ to the levels needed to protect vulnerable patients (7).

Influencing factors for low influenza immunisation amongst health care workers

Vaccination rates worldwide remain low despite strong evidence that immunisation of health care workers (HCWs) against flu is effective in preventing the spread of disease, lowers mortality rates among patients8,9, and that influenza infections in hospital health care workers lead to nosocomial outbreaks (10).

One qualitative research study found that nurses who chose not to be vaccinated did so for reasons of personal health choice and/or the perceived risk of injury or illness to themselves. The nurses viewed vaccination as a personal health choice and not an evidence-based nursing intervention. Patient safety outcomes were also mentioned as a factor influencing their decision to decline vaccination (11).

In another study undertaken in Minnesota, during the 2009 pandemic influenza outbreak, found a significant difference in vaccine uptake between doctors and nurses with 85 per cent of doctors and 62 per cent of nurses being vaccinated. More doctors than nurses chose vaccination because they believed they could accurately estimate their risk of side effects, while others identified a need to meet their professional obligation to be vaccinated and felt an ethical obligation to follow public health authorities’ recommendations and laws mandating pandemic vaccination (12).

A strong sense of professional responsibility was the strongest predictive factor for vaccination in a Saudia Arabian research project, as was previous positive experiences of vaccination (13).

A literature review of global barriers to vaccination uptake revealed consistent emergent themes across the varied nations carrying out the research studies. Themes identified included: fears about vaccine side effects; doubts around vaccine safety, efficacy and benefits in both pandemic and seasonal influenza scenarios; not viewing influenza as a serious illness; fear of contracting influenza; and fears that the vaccine could cause other illnesses such as Guillain-Barre syndrome and even infertility (14,15,16, 17).

Though recommended by many, and mandated by some, flu vaccination rates among HCWs, even in pandemics, remain below optimal levels (12).

Addressing the fears around vaccination

The latest Seasonal Influenza Vaccine report issued in New Zealand by the Centre for Adverse Reactions Monitoring (CARM)(18) reveals the number of adverse events reported in recent years (see Table 1).

The most commonly reported events were injection site inflammation [45 reports], fever [24], arm pain [22], vomiting [20] and headache [20].

On reviewing these results, several conclusions can be drawn. It appears that the number of adverse events reported in contrast to the potentially large number of vaccine doses administered is in fact very small. In 2012, adverse events equated to just 0.02 per cent and none of these events were life threatening. Also, while the type of adverse event reported may dissuade individuals from seeking vaccination, because of the temporary inconvenience of symptoms experienced, the actual or perceived threat of adverse events in this instance appears scientifically unsubstantiated.

A limitation of the CARM data is that only those who report adverse events post- vaccination are included in the results. How many went unreported? The robustness of the CARM data may be enhanced by identifying actual numbers of vaccines administered and providing more detail on those who reported events – e.g. age, gender plus how, where and when they were vaccinated. This may help in identifying trends. It may also be interesting to identify how many individuals actually contracted influenza post-vaccination? There is anecdotal evidence to suggest that some people do experience varying degrees of influenza-type illness post-vaccination and while other factors may contribute to individuals becoming unwell, is this a factor that contributes to reduced uptake of vaccination?

A review of the literature found no evidence to support or substantiate influenza vaccination causing infertility. There was a small link between influenza vaccination and Guillain-Barre Syndrome identified in America in the 1970s but those vaccine components have long since been discontinued and therefore pose no current threat.

Raising influenza vaccination uptake rates

Research study findings have identified a number of recommendations to raise influenza immunisation rates globally among health care workers. These include: improving education around vaccine use for health care workers to dispel myths and raise awareness (21); using the past and present experiences of influenza events to improve pandemic awareness and vaccination programme management targeted specifically at health care workers (22); starting education campaigns much earlier in a pandemic; (23) ensuring health care workers have access to scientific literature; having trust in public health communications and messaging; receiving encouragement from loved ones, physicians and co-workers; having access to vaccine campaigns that emphasise benefits of vaccination and highlight positive cues to vaccination while addressing barriers to vaccine uptake (24); effectively managing media to enhance the scientific validity of vaccination and influenza events reporting (25); and making health care worker vaccination mandatory26.

Vaccination: personal choice, professional responsibility or mandatory expectation?

Making health care worker vaccination mandatory has proved effective in improving influenza immunisation rates. Where this has been implemented, however, this has been met with resistance and caused controversy and substantial discontent (27). Controversy and discontent were in conflict over freedom of choice versus the mandate to ‘do no harm’ and ‘act in patients’ best interests. Freedom of choice breaches have the potential to adversely impact on individuals’ decisions based on religious, medical, or philosophical beliefs. The WHO, while advocating strongly for high health care worker vaccination levels, also respect individuals’ rights to abstain from vaccination on religious or medical grounds.

The costs of low influenza vaccination uptake rates among health care workers.

There is evidence of increased incidences of nosocomial influenza infections in hospital and community health care environments where vaccination rates are low28. The highly infectious nature of influenza can result in decimated health care worker numbers very quickly, even within immunised environments. The costs associated with managing seasonal, epidemic and pandemic influenza events – such as hospitalisation of infected people and replacing ill staff ­­– can be billions of dollars29. Costs not only impact on health spending budget and health care organisations but also on individuals who potentially lose wages if unable to work for lengthy periods because they are unwell. Most sick leave allocations are minimal and just one ill health event that stops you working for even a couple of weeks can use up this precious resource very quickly. The threat of financial hardship is very real. Many colleagues will continue to work while experiencing varying degrees of influenza-type symptoms because the threat of financial hardship often precludes staying away from work or because they believe their own immune system will fight the infection. Unfortunately this only aids the spread of infection to patients and colleagues alike. Organisational policies aimed at containing the spread of influenza by sending sick staff home early, at symptom onset, are often not implemented.

Minimising the costs through managing the risks

Being vigilant with basic hand hygiene practices and following a lifestyle that promotes optimal health and well being have a valuable part to play in minimising the potential spread of influenza. Some other interventions for implementation can include health promotion campaigns such as advising people if they are feeling unwell to stay at home until they are better; to if possible take advantage of influenza vaccination; and to ensure adequate food stocks, medicines and tissues are available should they need to stay home in cases of seasonal, epidemic or pandemic influenza30. On April 1 this year, PHARMAC (New Zealand’s pharmaceutical management agency) extended the eligibility criteria for people receiving free influenza vaccination in a bid to prevent and or minimise disease spread and adverse population impacts31. Organisations may also benefit from reviewing their policies on staff sick leave for people demonstrating flu-like symptoms so that these can be implemented more efficiently and minimise infection spread to patients and colleagues alike.

Conclusion

Research has identified that influenza vaccination albeit for seasonal, epidemic or pandemic containment appears to be a lower priority for health care workers globally, especially nurses. Decisions about vaccination appear to be influenced by and closely linked to personal, professional and ethical beliefs, values and knowledge, which can cause conflict and confusion for health care workers.

Research has also identified that low vaccination uptake rates among health care workers are often related to fear and are not scientifically substantiated. Common fears include: fear of contracting the illness, experiencing vaccine side effects and doubts about vaccine efficacy. Educating health care workers using relevant, evidence-based information presented in a timely and effective manner is one intervention recommended for improving influenza vaccination uptake rates. Recommending mandatory vaccination for all health care workers to improve immunisation rates has resulted in some conflict and resistance. Health care workers believe their human right to choose in this instance has been superseded by the organisational and professional expectations to do no harm and act in the patients’ best interests. The WHO respects individual’s rights to choose to decline vaccination on the grounds of religious or medical grounds. Maintaining optimal health and wellness, coupled with vigilance when implementing basic hand and other hygiene measures are also effective in minimising the spread of influenza.

Responsibility for managing influenzas effectively and efficiently is a challenge for everyone. The costs of failing to do so are significant for nurses, their clients, colleagues, employing organisations, communities, health funding, governments, and global health outcomes. The World Health Organisation has and continues to develop new initiatives aimed at containing and effectively guiding the management of influenza outbreaks globally. The need for ongoing robust discussions, decisions, and actions to effectively manage the constant threat of rapidly mutating influenza virus strains remains ever present as will the debate about the role of vaccination in assisting this.

A quote from Hippocrates in closing: “A wise man should consider that health is the greatest of human blessings and learn how by his own thought to derive benefits from his illnesses”(32).

About the author:

Noreen McLoughlin RN MA (Applied) Diploma Adult Education & Training is an independent health auditor, self-employed professional evelopment consultant for the last seven years, and a registered nurse for 30 years.

This article was peer reviewed by:

• Nicola Russell RN BN M.Phil (Nursing) primary health care nurse, Invercargill and board member of College of Nurses Aotearoa (NZ).
• Gillian Sim RN BHSc, MA(hons) nurse researcher and public health nurse, Southern District Health Board.

Acknowledgements

My thanks are extended to the following people for their assistance in helping me track down and access some relevant research information for this article: Theo Brandt, communications manager for Immunisation Advisory Centre, University of Auckland; Michelle Kapinga and Brenda Saunders of the National Influenza Specialist Interest Group; Dr Michael Tatley, the Director of CARM; and Cory Vessey, Ministry of Health immunisation advisor.

View PDF of this article (and related learning activity) here >>

REFERENCES

1. WORLD HEALTH ORGANISATION (2012) Meeting of the Strategic Advisory Group of Experts on Immunisation April 2012, Conclusions and Recommendations. WER, 2012, 21, 87, 201-216
2. CENTRES FOR DISEASE CONTROL AND PREVENTION (2013) http://www.cdc.gov/vaccines/vac-gen/immunity-types.htm Retrieved May 2013
3. IMMUNISATION ADVISORY CENTRE Duration of Protection, Efficacy and Effectiveness http://www.immune.org.nz/category/tags/vaccine-duration retrieved May 2013
4. CENTRES FOR DISEASE CONTROL AND PREVENTION (2013) http://www.cdc.gov/vaccines/vac-gen/immunity-types.htm Retrieved May 2013
5. IMMUNISATION ADVISORY CENTRE (2013) Immunisation overview 2013 www.immune.org.nz Retrieved May 2013
6. MINISTRY OF HEALTH Workforce Influenza Coverage Rates 2010-2012 (November 20 2012 update) http://www.health.govt.nz/our-work/preventative-health-wellness/immunisation/updates-immunisation Retrieved 20 May 2013
7. JENNINGS L Call for more nurses to get ‘flu jabs, Nursing Review News Feed April 2 2013 (from NISG press release March 27)
8. HAYWARD A, HARLING R, WETTEN S, JOHNSON,AM, MUNRO S, SMEDLEY J, MURAD S, AND WATSON J (2006) Effectiveness of an influenza vaccine programme for care home staff to prevent death, morbidity and health service use among residents: cluster randomised controlled trial. British Medical Journal. 2006 Dec, 333 7581, p1241 retrieved from the Cochrane library April 16 2012
9. CARMAN W, ELDER A, WALLACE L, MCAULEY K, WALKER A, MURRAY G, AND STOTT D (2000). Effects of influenza vaccination of health care workers on mortality of elderly people in long term care: a randomised controlled trial. Lancet 2000 Jan, 355 9198, pp 93-97. Retrieved from the Cochrane library April 16 2012
10. VOIVIN N, BARRET B, METZGER M AND VANHEMS P (2009). Hospital Acquired Influenza. Synthesis using the outbreak reports and interventions studies of nosocomial infection statement. Journal of Hospital Infections 2009, 71: 1-14
11. RHUDY L, TUCKER S, OFSTEAD C AND POLAND G (2010) Personal choice or evidence-based nursing intervention: nurses’ decision-making about influenza vaccination. Worldviews Evidence Based Nursing 2010 Jun 1;7(2):111-20 Epub 2010 Mar
12. HENRIKSEN HELLYER J, DEVRIES A, JENKINS S, LACKORE K, ZIEGENFUSS J, POLAND G, AND TILBERT J (2011) Attitudes and uptake of H1N1 vaccine among health care workers during the 2009 H1N1 Pandemic. Plos One, 2011;6(12) epub 2011 Dec 22.
13. AL-TAWFIQ JA (2012) Willingness of health care workers of various nationalities to accept H1N1 (2009) pandemic influenza A vaccination. Ann Saudi Med, 2012 Jan-Feb:32(1):64-7
14. AGUILAR-DIAZ FEDL C, JIMENEZ-CORONA M, PONCE-DE-LEON-ROSALES S (2011) Influenza vaccine and health care workers. Arch Med Res, 2011 Nov;42(8):652-7 Epub 2012 Jan 4.
15. CHOR J, NGAI K, GOGGINS W, WONG M, WONG S, LEE N, LEUNG T, RAINER T, GRIFFITHS S, AND CHAN P (2009). Willingness of Hong Kong health care workers to accept pre-pandemic influenza vaccination at different WHO alert levels: two questionnaire surveys. British Medical Journal. Aug 2009. http://www.ncbi.nlm.nih.gov/pubmed/19706937 Retrieved May 2013
16. ALKUWARI M, AZIZ N, NAZZAL Z, AND AL-NUAIMI S (2011) Pandemic Influenza A/H1N1 vaccination uptake among health care workers in Qatar: motivators and barriers. Vaccine 2011 Mar 3;29(11):2206-11
17. BOHMER M, WALTER D, FALKENHORST G, MUTERS S, KRAUSE G, AND WICHMANN O (2012) Barriers to pandemic influenza vaccination and uptake of seasonal influenza vaccine in the post-pandemic season in Germany. BMC Public Health 2012 Oct 31,12:93.
18. CARM (2012) Seasonal Influenza Vaccine Reports in 2012. Retrieved from www.medsafe.govt.nz May 2013
19. World Health Organisation, Global Vaccine Safety Initiative http://www.who.org Retrieved May 2013
20. World Health Organisation, Global Vaccine Safety Blueprint http://www.who.org Retrieved May 2013
21. TORUN S, AND TORUN F (2010) Vaccination against pandemic influenza A/H1N1among health care workers and reasons for refusing vaccination in Istanbul in last pandemic phase. Vaccine 2010 Aug 9;28(35):5703-10 epub 2010 Jun 30
22. WICKER S, RABENAU H, BIASH, GRONEBURG D, AND GOTTSCHALK R (2010) Influenza A (H1N1) 2009: Impact on Frankfurt in due consideration of health care and public health. J Occup. Med Toxicol, 2010 April 26;5:10
23. SEALE H, KAUR R, WANG Q, YANG P, ZHANG Y, WANG X, LI X, ZHANG Z, AND MACINTYRE C (2011) Acceptance of a vaccine against pandemic influenza A (H1N1) virus amongst health care workers in Beijing, China. Vaccine 2011 Feb 11;29(8):16705-10
24. PREMATUNGE C, CORACE K, MCCARTHY A, NAIR RC, PUGSLEY R, AND GARBER G (2012) Factors influencing pandemic influenza vaccination of health care workers-a systematic review. Vaccine, 2012 Jul 6;30 (32):4733-43
25. PETOUSIS-HARRIS H, GOODYEAR-SMITH F, KAMESHWAR K, AND TURNER N (2012) Fact or Fallacy? Immunisation arguments in the print media. Australian and New Zealand Journal of Public Health 34(5), 2010 521-526
26. HOLLMEYER H, HAYDEN F, MOUNTS A AND BUCHHOLZ U (2012) Interventions to increase influenza vaccination among health care workers in hospitals. Influenza and other respiratory viruses 2012. DOI: 10.111/irv.12002
27. CHOR J, PADA S, STEPHENSON I, GOGGINS W, TAMBYAH PA & ET AL (2011) Seasonal influenza vaccination predicts pandemic H1N1 vaccination uptake among health care workers in three countries. Vaccine Oct 6:29(43) epub 2011 Jul 30.
28. SALGADO C, FARR B, HALL K AND HAYDEN F (2002) Influenza in the acute hospital setting. Lancet Infectious Diseases 2002; 2:145-155
29. DOHERTY P Vets and viruses (2013) Radio Broadcast with Kim Hill, Radio NZ National, Saturday May 18 2013.
30. Ministry of Health (2013) Influenza www.health.govt.nz/your-health/conditions-and-treatments/diseases-and-illnesses Retrieved May 2013
31. PHARMAC (Pharmaceutical Management Agency) (2013) Amendment to Influenza Vaccine Funding Criteria
32. Hippocrates www.brainyquotes.com