Michele G. Sullivan is in the Mid-Atlantic bureau of Elsevier Global Medical News.
Approved in September and scheduled to get into providers' hands starting early this month, vaccines for the pandemic A(H1N1) flu could protect nursing home staff and, in turn, residents. But how many of those caregivers and other health care workers would accept the vaccine remained in doubt early in this unusual flu season.
Recent epidemiologic data show that U.S. infections with H1N1 flu are rising rapidly, according to Anne Schuchat, MD, director of the Centers for Disease Control and Prevention National Center for Immunization and Respiratory Diseases. The CDC reported that during the third week of September, influenza cases were in all 50 states, with widespread activity in 26 states.
“It's very strange to see this kind of activity at this time of year,” said Daniel Jernigan, MD, deputy director of the CDC's influenza division. The new spike of flu cases has been most dramatic in states in the southeastern United States, he added. Dr. Jernigan joined other CDC officials in speculating that this pattern may be linked to an early start to the school year for many districts in those states.
The “vast majority” of circulating influenza was the pandemic H1N1 type, Dr. Jernigan said. During the first 2 weeks of September, 4% of visits to CDC sentinel providers of outpatient or emergency department care were for flulike illness. That rate is as high as that seen in February 2009, the most recent peak of seasonal influenza in the United States, CDC reported.
Notable features of the H1N1 infection pattern have been higher-than-usual infection rates in people aged 5–17 and 18–49 and the lowest hospitalization rates for H1N1 infections among people aged 65 and older, who for seasonal flu are typically the most hospitalized group, Dr. Schuchat said. Such patterns last spring led the CDC to place people 65 and older outside the five target groups for H1N1 vaccinations, as long as they were free of risk factors for influenza-related complications. On the other hand, health care personnel were among the most targeted groups for the vaccine.
Even before the Food and Drug Administration approved four H1N1 vaccines Sept. 15, the Association for Professionals in Infection Control and Epidemiology (APIC) urged all health care institutions, including nursing homes and skilled nursing facilities, to require their employees to be vaccinated. If workers decline vaccinations, they should be required to sign a statement acknowledging that their action may put patients at risk of contracting the disease, according to the ACIP policy paper.
“Employees who are not vaccinated can transmit both seasonal flu and H1N1 virus to vulnerable patients in health care situations,” Christine J. Nutty, RN, president of the association, said in a statement. “Current rates of health care worker immunizations are appallingly low and must not be tolerated.”
Despite past CDC recommendations for health care worker vaccinations, APIC cited survey data from 2005 to 2006 showing that just 42% of those with patient contact had been vaccinated against seasonal influenza. “We want to be certain that health care personnel are protected against both seasonal flu and the 2009 H1N1 virus,” said Linda Greene, RN, lead author of the APIC position paper and the director of infection control at Rochester (N.Y.) General Health System. “Otherwise, facilities could face a double problem of increased illness and absenteeism among staff coupled with overcrowded emergency departments.”
Practitioners aren't the only ones who should be vaccinated, the paper said. “All employees with direct patient contact should be immunized annually, including physicians, nurses, therapists, dieticians, religious workers, environmental services, and kitchen staff.”
A survey last spring in 31 Hong Kong hospitals offered little encouragement for that point of view. Only 48% of health care workers were willing to accept prepandemic influenza vaccinations to either the H5N1 or the novel H1N1 viruses, researchers found. The most common barriers to vaccination were worries about side effects and doubts about effectiveness, lead authors Josette Chor and Paul Chan, MD, wrote in BMJ online (BMJ 2009;doi:10.1136/bmj.b3391). The researchers conducted the survey in May, after the World Health Organization alert level for H1N1 had been raised to phase 5. Nurses accounted for 71% of the respondents and physicians for 19%.
The authors said they were surprised at the low level of willingness to take a vaccine despite past experiences with the severe acute respiratory syndrome (SARS) in Hong Kong.
The specter of Guillain-Barré Syndrome associated with the 1976–1977 swine flu vaccine probably bears on the survey's results, Rachel Jordan, MD, of the University of Birmingham, England, and Andrew Hayward, MD, of the University College of London wrote in an editorial accompanying the report (doi:10.1136/bmj.b3391).
“This rare event had decreased greatly during the past 15 years, to around 0.7 reports per million vaccinations. Indeed, recent research suggests no significant increase in the risk of this syndrome after vaccination, but a greater risk after natural influenza infection,” Dr. Jordan and Dr. Hayward wrote. “Flu vaccination is likely to reduce this risk and has a well-understood safety profile. Vaccination may also help to keep the healthcare system operating at maximum capacity throughout the pandemic.”
Beyond vaccination, the Institute of Medicine in Washington said that health care workers should wear N95 respirators or better when in close contact with confirmed or suspected H1N1 influenza cases. Explicitly including “health care workers … in non-hospital settings,” the IOM endorsed existing CDC guidelines for protection and urged that the respirators be only one element of infection-control strategies.
Other measures to control the spread of the novel H1N1 virus currently recommended by the CDC include wearing gloves and gowns when in contact with infected persons, practicing proper hand hygiene, covering coughs and sneezes, and isolating individuals who appear ill.
“There's no such thing as a risk-free environment,” said Dr. Rosemary Sokas of the Occupational Safety and Health Administration. But she emphasized that employers are responsible for providing workers with the highest level of protection possible.
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