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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 , arm pain , vomiting  and headache .
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.
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.
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.
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