Monday, December 3, 2012

Research doesn't support mandatory influenza vaccination / WMJ

From the Mayo Clinic and Wisconsin Medical Journal comes the following letter from Preventive Medicine specialist William Buchta, M.D., MPH:
While the intent of Aurora’s mandatory influenza vaccination1
of health care workers might
be noble, ie, patient protection, the research on the subject is lacking. Only 2 studies have tracked hospital-acquired worker-to-patient
influenza (a relatively simple infection control
metric) and both reported cases in the single
digits for an average-sized hospital over multiple
complete flu seasons.2,3

In fact, the latter
demonstrated that influenza made up only 23%
of strains causing influenza-like illness (ILI),
such that the rate for true worker-to-patient influenza infection for a 400-bed hospital is less than 1 case per year. Why? Influenza is a
community-acquired disease, and standard infection control precautions (hand-washing, masking those with a cough, isolation, and visitor control) curb transmission in hospitals.  Ironically, vaccination is possibly the least effective of these measures, and CDC data and
at least 1 study cited below have demonstrated
that over the recent past, influenza vaccine is
between 40% and 63% effective, on average.
Influenza is only one of a host of viruses that
can sicken a hospitalized patient, but is the
only one for which we have a vaccine. Yet the other control measures I mentioned are efficacious against ALL such organisms. Why don’t we make those measures mandatory? 
Last year at Mayo Clinic Rochester, we instituted
mandatory compliance with an influenza
control program for all employees with patient
contact: get vaccinated or sign an electronic
declination that included education. With over
25,000 such employees, everyone complied,
no one lost a job, and 93% chose vaccine vs
declination. We emphasized personal, family,
and patient protection, and it was perceived
as a benefit. We also emphasized other control measures, such as handwashing and staying home when ill, to control the ILIs for which we have no vaccine. Call it "Minnesota nice," but it can be done.
Influenza vaccination is important
but not worth terminating employment or disgracing
a worker by forcing him or her to wear
a mask the entire flu season (an alternative
control at other medical centers) when there is no evidence that it will prevent infections. 
In due time, possibly the next 5 years, we
will have a better influenza vaccine that targets
common antigens on all strains of influenza
and that may not require annual vaccination.
Employees who choose not to be vaccinated are not lunatics; they have endured the long lines to be vaccinated, they have been turned away during rationing, they (or co-workers) have gotten influenza despite vaccination.  
When we have a decent vaccine, like MMR or
dT, we won't have to twist arms; everyone will
get it. If we are going to regulate and scrutinize
our dedicated health care workers any further,
let's do it for the right reason. The American
College of Occupational and Environmental
Medicine’s guidance statement4
outlines a more balanced approach to this issue.
William G. Buchta, MD, MS, MPH
Mayo Clinic Division of Preventive,
Occupational, and Aerospace Medicine,
Rochester, Minn 
1. Smith DR, Van Cleave B. Influenza vaccination as a
condition of employment for a large regional health
care system. WMJ. 2012;111(2):68-71.
2. Salgado CD, Giannetta ET, Hayden FG, Farr BM.
Preventing nosocomial influenza by improving the
vaccine acceptance rate of clinicians. Inf Control and
Hosp Epid. 2006;25(11):923-928.
3. Vanhems P, Voirin N, Roche S, et al. Risk of
influenza-like illness in an acute health care setting
during community influenza epidemics in 2004-2005,
2005-2006, and 2006-2007: a prospective study.
Arch Intern Med. 2011;171(2):151-157.
4. American College of Occupational and
Environmental Medicine. Seasonal Influenza
Prevention in Health Care Workers. Guidance statement. November 17, 2008.
aspx. Accessed May 22, 2012.

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