Influenza vaccination and health care workers: The current dilemma

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The specter of influenza epidemics

Influenza is the sixth leading cause of death in the U.S. (~36,000 per year, 5-20% of the population infected) and is responsible for upwards of 200 million days of restricted activity, 75 million work absentee days, 22 million health care facility visits and 110,000-200,000 hospitalizations each year (Backer, 2006; Bartlett, 2006; Centers for Disease Control and Prevention [CDC], 2005a, 2006a; Hoffmann & Perl, 2005; King, Woolhandler, Brown, Jiang, Kevorkian, Himmelstein, et al., 2006; Lester, McGeer, Tomlinson, & Detsky, 2003). Worldwide, the disease kills between 250,000 and 500,000 people per year (Poland, Tosh & Jacobson, 2005). In addition, Backer (p. 1144) observes that “deaths due to influenza and pneumonia….greatly exceed the death toll from AIDS and these [two] illnesses rank in the top 10 causes of death for every decade of life.” Economically-speaking, influenza epidemics cost the U.S. economy approximately $12 billion a year, most of which is “manifested in indirect costs…associated with losses in productivity and school or work absenteeism” (Mair, Grow, Mair, & Radonovich, 2006, p. 2).

The importance of immunization

Immunization is considered the safest and most effective method of preventing influenza (Backer, 2006; Poland et al., 2005), especially if vaccine is administered to those at greatest risk for disease complications. These ‘at-risk groups’ include (1) elderly individuals over 65 years of age, (2) children age 6-23 months, (3) pregnant women, (4) people with anemia and diabetes, (5) people with chronic lung, heart or kidney ailments and (6) those with diseases that suppress the immune system (CDC, 2005a; National Institutes of Health [NIH], 2005). Furthermore, these groups are often given priority in the event of a vaccine shortage (American College of Physicians, 2006; Heininger, Bachler, & Schaad, 2003).

There are numerous challenges to ensuring adequate vaccine supply during influenza epidemics, irrespective of actual demand. These challenges include: decreasing numbers of manufacturers, outright shortages (e.g., during the 2004-2005 flu season) and concerns over a potential flu pandemic (American College of Physicians, 2006; Bartlett, 2006; Desroches, Blendon & Benson, 2005; Gronvall & Borio, 2006; Mair et al., 2006; Offit, 2005; Oreinstein, Douglas, Rodewald & Hinman, 2005; Sloan, Berman, Rosenbaum, Chalk & Griffin, 2004; United States Government Accountability Office, 2005a, 2005b, 2005c, 2001; University of Pittsburgh Center for Biosecurity, 2005).

Influenza vaccination and health care workers: The current dilemma

CDC’s Advisory Committee on Immunization Practices (ACIP) is charged with setting U.S. vaccine policy. Each year since 1984, ACIP has recommended that all healthcare workers be immunized annually against influenza, due to the high risk of HCW-patient transmission in hospitals, nursing homes and other care settings (Backer, 2006; Carman, Elder, Wallace, McAulay, Walker, Murray et al., 2000; Hoffmann & Perl, 2005; King et al., 2006; Lester et al., 2003; Manuel, Henry, Hockin, & Naus, 2002; Martinello, Jones, & Topal, 2003; Pearson, Bridges & Harper, 2006; Simeonsson, Summer-Bean, & Connolly, 2004; Steiner, Vermeulen, Mullahy, & Hayney, 2002; Tapianinen, Bar, Schaad, & Heininger, 2005). These recommendations apply to providers in “acute care hospitals, nursing homes, skilled nursing facilities, physician’s offices, urgent care centers and outpatient clinics, and to persons who provide home health care and emergency medical services” (Pearson et al., 2006, p. 1).

Influenza transmission in healthcare settings presents ongoing challenges for disease control professionals (Hoey, 1998; Rea & Upshur, 2001). Goldstein, Kincade, Gamble and Bearman (2004, p. 908) observe that “healthcare facilities are an ideal environment for the rapid spread of influenza.” Lester et al. (2003, p. 839) observe, moreover, that “healthcare workers pose a potential risk for transmission of communicable disease in the hospitals and clinics in which they work…the healthcare setting has a high concentration of those at greatest risk of complications for influenza infection (i.e., the elderly and those with co-morbid conditions).” Similarly, Steiner et al. (2002, p. 625) state that “healthcare workers warrant particular focus because they are at risk of contracting influenza from patients and transmitting [it] to their patients.” Finally, Martinello et al. (2003, p. 846) argue that healthcare care workers “may act as potential vectors for nonsocomial transmission of influenza [because of] close contacts.”

Despite these risks and recommendations, influenza vaccination rates among healthcare workers remains chronically low, averaging between 15 and 40% nationwide (Heininger et al., 2003; Hoffmann & Perl, 2005; King et al., 2006; Manuel et al., 2002; Lester et al., 2003; Nuzzo, D’Esposo, Toner, Smith, Mair, & Hitchcock, 2006; Simeonsson et al., 2004; Steiner et al., 2002; Tapiainen et al., 2005; The Compliance Resource Center, 2006). This is despite efforts to encourage greater adherence to recommendations (King et al., 2006). This problem is not just limited to the United States; similar rates have been observed in Australia, New Zealand and Europe (Halliday, Thomson, Roberts, Bowen & Mead, 2003; Jordan, Wake, Hawker, Boxall, Frye-Smith, Chen et al., 2004; Murray & Skull, 2002). Within the United States, the CDC has made increasing rates an important priority, with Director Julie Gerberding stating that “when people who work in hospitals and healthcare facilities don’t get vaccinated, they can pose a serious health risk to their patients….these recommendations are designed to highlight the importance of healthcare personnel getting vaccinated each year” (The Compliance Resource Center, 2006, p. 1).

Identifying the audience

ACIP recommendations for influenza immunization apply to all healthcare workers with at least minimal patient contact. However, some groups are especially important by virtue of their place within the public health system - emergency and primary care physicians, nurses and first responders (e.g., paramedics) (Sokol, 2006). For CDC, immunizing these individuals is a top priority.

Emergency physicians are often on the front lines of medical emergencies, being the first to receive patients upon their arrival at hospitals. These individuals are responsible for prompt and accurate disease diagnosis, treatment and reporting (American College of Physicians, 2006; M’Ikanatha, Lautenbach, Kunselman, Julian, Southwell, Allswede, et al., 2003; Woods, McCarthy, Barry & Mahon, 2004). Furthermore, family physicians, given their familiarity and possible close relationship with their patients, may serve as valuable sources of information and treatment at times of sickness (Stein, Tanielian, Ryan, Rhodes, Young & Blanchard, 2004). In some instances, these individuals may even be the primary source of emergency medical care (Marshall, Begier, Griffith, Adams, & Hadler, 2005; Quinn, Thomas & McAllister, 2005).

Case-based research and anecdotal evidence highlight the valuable role these two physician groups play during times of crisis (American College of Physicians, 2006; American College of Emergency Physicians, 2006; College of Family Physicians of Canada, 2005; RAND Corporation, 2006; Wray & Jupka, 2004). For example, during the fall 2001 anthrax attacks, private (family) physicians emerged as a key source of health information. Quinn et al. (2005, p. 210), in focus groups with postal workers employed at facilities contaminated by anthrax, found that many consulted personal physicians when “making health and safety decisions.” This parallels work by Stein et al. (2004), which found that Capitol Hill and Washington D.C. postal employees relied heavily on their private physicians in deciding whether to adhere to prophylactic antibiotics. Similarly, in survey research on public perceptions of smallpox, Marshall et al. (2005) found a strong public preference for emergency and family physicians as treatment sources.

For similar reasons, nurses and paramedics are also valuable healthcare professionals. Although emergency physicians are often the first to diagnose and treat patients upon arrival at hospital, paramedics are often true first responders, arriving on the scene to treat and stabilize the wounded (Markenson, Reilly, & DiMaggio, 2005). In addition, nurses are important sources of patient care and physician assistance. In particular, the nurse practitioner – who can provide basic care without physician supervision – has emerged as an important resource in instances of limited physician availability (Chang, Hawkins, McGirr, Fielding, Hemmings, O’Donoghue et al., 1999; Tye, 1997). Furthermore, research has focused on the potential role of nurses in responding to infectious disease outbreaks such as bioterrorism, not to mention actual examples in which nurses found themselves on the front lines of major public crises (e.g., SARS in 2003) (Guillon, 2004).

Taken together, these groups of healthcare workers are vital sources of medical care. However, their positions put them at risk for the very diseases they aim to treat (American College of Physicians, 2006; Henderson, 1999). During the 2003 SARS outbreak and the 1918 influenza pandemic, for example, healthcare workers accounted for a significant portion of the dead and incapacitated (Bartlett, 2006; Guillon, 2004; Schoch-Spana, 2000). Their conspicuous absence can hinder an effective health response. They also risk spreading disease to patients and colleagues (Carman et al., 2000; King et al., 2006; Pearson et al., 2006; Simeonsson et al., 2004). Therefore, it becomes especially crucial that they take all necessary protective measures, including receiving vaccines where recommended.

Strategies for increasing HCW immunization rates

Currently, healthcare workers are not required to receive influenza vaccine. Moreover, facilitating higher immunization rates is difficult (Finch, 2006). Campaigns to immunize healthcare workers against other diseases have encountered similar challenges. For example, shortly after the September 11th attacks, President Bush initiated a voluntary smallpox vaccination program for all healthcare workers, with the goal of immunizing 500,000 individuals (Barlett, Borio, Radonovich, Mair, O’Toole, Mair, et al., 2003). Although the program was voluntary and research suggested many workers were willing to be vaccinated (Yih, Lieu, Rego, O’Brien, Shay, Yokoe, et al., 2003), rates varied tremendously by state and region, with some health facilities (e.g., hospitals) and individuals refusing to participate. By week 10 of the program (April 4th, 2003), only 6 percent of the 500,000 workers had been immunized. Two obstacles affected progress – the heavy demands the program placed on CDC and other agencies, as well as hesitation on the part of local/state heath departments and hospitals to participate (US Government Accountability Office, 2003).

Despite these experiences, CDC has proposed a number of strategies for increasing influenza vaccination rates among healthcare workers. From a supply-side perspective are recommendations for increasing the availability of vaccines and offering them at free or reduced prices. From a demand-side perspective are recommendations related to the following

  • Framing vaccination as an ethical responsibility (“do no harm”), in which healthcare workers are obliged to do everything possible to safeguard their own health and the health of their patients (Backer, 2006; Poland et al., 2005; Rea & Upshur, 2001).

  • Stressing that the vaccination is safe and effective (Backer, 2006).

  • Emphasizing the cost-effectiveness of vaccination - “[Healthcare] facilities are almost always short-staffed and short-bedded during the influenza season, so it is clearly to employer’s benefit to keep their employees in healthy, working condition [via vaccination] (Backer, 2006, p. 1145).

Vaccine risk communication: Towards a focus on vaccine behavior

Risk communication is a social science discipline that focuses on disseminating information about perceived hazards in times of stress, crisis or emergency (Morgan, Fischoff, Bostrom & Atman, 2002). The aforementioned demand-side strategies for increasing HCW vaccine uptake imply a strong role for risk communication in persuading individuals to be immunized. Pearson et al. (2006, p. 2) state that vaccine risk communication involves information “regarding the benefits of influenza vaccination and the potential health consequences of influenza illness for [healthcare workers] and their patients, the epidemiology and modes of transmission, diagnosis, treatment, and non-vaccine infection control strategies, in accordance with their level of responsibility in preventing health-care-associated influenza.”

However, communicating about vaccination is a challenging proposition. First, it is a decision involving both individual and societal considerations. It provides a clear benefit to the individual (avoiding disease) and an even larger, abstract benefit to society (preventing disease transmission to others). However, communicating about abstract benefits that extend beyond the individual (patient health, in the case of influenza vaccination) is notoriously difficult (Kahlor, Dunwoody, Griffin & Neuwirth, 2006). Second, communication is more than just providing information; it also involves developing messages that address salient beliefs and attitudes. To change behavior, communicators must understand what informs such behavior in the first place. To affect risk decisions, one must understand how they are made. Education is not akin to persuasion. Instead, just as public relations and marketing stress the importance of ‘knowing your audience,’ so too should risk communication develop more effective messages that address the salient attitudes of healthcare providers. Specifically, this involves exploring the theoretical determinants of vaccine behavior and decision-making.

Ethics of persuasion

Persuading healthcare workers to be vaccinated involves several ethical considerations. Indeed, ethical issues arise whenever risk communication is used to facilitate behavior change (Bostrom & Lofstedt, 2003; McComas, 2006).

Currently, neither influenza vaccine nor any other immunization is mandatory for healthcare workers. Therefore, using persuasion to change vaccine behavior presents an ethical dilemma – namely, the right of the individual to choose vaccination versus the ‘public good’ (e.g., protecting patient health) (Clements & Ratzan, 2003; Petts & Neimeyer, 2004). Some may view persuasion as a thin-veiled attempt at coercion. Moreover, Bostrom and Lofestedt (2003) warn that well-intentioned communication efforts designed to reduce health risks may run afoul if they are seen as infringing on personal liberties. They observe that “it is all too easy to loose…civil liberties and equal treatment of citizens in our eagerness to reduce risks” (p. 243).

Other ethical issues center on a preoccupation with vaccine communication to the detriment of other potentially effective strategies, such as increasing vaccine supply and enhancing availability. Finally, persuasion may have unanticipated (and undesired) consequences should it fail to address issues such as: (1) the potential for strained relationships between medical providers and management over the issue of immunization, (2) legal implications of forcing workers to be immunized (e.g.,, who will handle lawsuits that may arise as a result of side effects) and (3) the concern that increasing HCW rates neglects focusing on other, equally at-risk groups (such as the elderly and children) (Finch, 2006).

However, at the same time, the health consequences of HCW-patient transmission of influenza are well documented, and the efficacy of risk communication in facilitating behavior change well-researched. The presence of ethical implications, this thesis argues, does not preclude the use of risk communication as a key resource in protecting public and provider health, so long as such implications are acknowledged.

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