Furthermore, the United States has been relatively unaffected by an influenza pandemic since the late 1960s. Even last year’s resurgence of swine flu did not reach the proportions initially feared, although certain populations (including pregnant women) were disproportionately affected. Anyone who acquired swine flu understands how debilitating, if not deadly, an illness it can be—but since many Americans didn’t experience it, perhaps we do not appreciate the harm any strain of influenza can cause.
“I think one of the overriding factors is a lack of understanding of how serious a disease influenza is,” says SHEA’s Fishman. “Every year in the US, 40,000 people die of influenza or influenza-related illnesses. I just don’t think people are aware that influenza is the leading cause of vaccine-preventable death in this country.”
Another piece of the problem is how frequently flu is misidentified. “We talk about all illnesses that occur in the fall and winter as ‘the flu,’” Poland points out. “But 90% or so of those illnesses are not influenza and indeed are mild. And so, by misnaming those, we inculcate a culture that sees influenza as a minor annoying illness.”
Poland further breaks down the figure of 40,000 deaths annually: “In the next four to six months, about one out of every 8,000 Americans alive right now is going to die of influenza. That number shocks health care workers. And yet, it shouldn’t. Those numbers have been well known for some time.”
A Matter of Patient Safety
Even for individuals who consider the low rates of influenza vaccination among health care providers to be problematic, the idea of a mandate on the subject rankles. “The culture in America is such that if somebody tells you that you have to do something, the hair on the back of your neck stands up a little bit,” Poland says. “I do understand that.”
However, the bottom line for SHEA, IDSA, AAP, and other organizations is that influenza vaccine is a patient safety issue. “We’re absolutely convinced, from examination of the data, that patient safety is enhanced and lives are saved when we make this a requirement,” Poland says. “And it’s informed by decades of trying to do it on a voluntary basis and simply not making progress.”
“One of the reasons SHEA decided to go forward with this statement is that the evidence supporting mandatory vaccination is irrefutable,” adds Fishman. “It is very clear now that vaccination of health care providers decreases mortality in patients. And it’s difficult to ignore that.”
The data referred to are cited in SHEA’s position paper and were originally published in journals ranging from the Lancet and BMJ to the Journal of Infectious Diseases and the Journal of the American Geriatrics Society. For example, a modeling study indicated that when 100% of health care personnel in an acute care setting are vaccinated against flu, the risk for the illness is reduced by 43% among hospitalized patients and 60% among nursing home patients. Multicenter randomized controlled trials have demonstrated that vaccination of health care workers significantly decreases mortality risk among patients in long-term care settings.
The AAP paper, on the other hand, cites two published studies (both in Infection Control and Hospital Epidemiology) that reveal the negative consequences when health care providers have not received their flu vaccine. In one, 35% of infants in a neonatal ICU were infected with influenza as a result of health care–associated transmission. Six of the 19 infants became ill and one died; a survey of the ICU staff revealed that only 15% of respondents had been vaccinated against influenza. In the other study, which was conducted in a bone marrow transplant unit, seven cases of health care–associated pneumonia occurred; six patients developed pneumonia and two died. The reported vaccination rate among the unit’s staff was 12%.
In light of such information, it is hard to argue when Killeen says that institutions should make influenza vaccine readily available to health care providers, free or at a discounted rate, and provide appropriate education about immunization. “I’m happy that both organizations, SHEA and IDSA, make it clear that ‘noncompliance should not be tolerated,’ because we really should be encouraging vaccination and make health care providers understand the importance of it,” he says, although he adds, “Taking the step to mandating it is a difficult step for me, personally.”
But experts like Fishman and Poland say that the mere accessibility of vaccine has not led to unmitigated success: You may provide it, but still they won’t all come. “Most institutions have tried that—make the vaccine free, make it convenient,” Poland observes. “All of those things do help. But there does appear to be a ceiling—somewhere between 20% to 40%—where, even with all those factors, even with decades of education, people still do not respond.”