FAQ: Current state of debate and evidence in the peer-reviewed literature on HCP influenza vaccination?

What is the current state of debate and evidence in the peer-reviewed literature on HCP influenza vaccination rates, mandated programs and related issues? [FAQ Date: April 1, 2013]

We provide below citations and abstracts/excerpts from current literature to provide some opening perspectives:

Influenza Prevention Update – Examining Common Arguments Against Influenza Vaccination
Thomas R. Talbot, MD, MPH; H. Keipp Talbot, MD, MPH
JAMA. 2013;309(9):881-882. doi:10.1001/jama.2013.453.
Viewpoint | March 6, 2013 ONLINE FIRST
Following last year’s season of low activity, influenza is surging across the country and as of January 5 has claimed the lives of 20 children.1 With influenza intensifying, it is important to review essential interventions that prevent influenza transmission at home, at work, and in health care facilities.

Several important actions should be performed by everyone to prevent the spread of this potentially deadly pathogen. Basic infection control practices such as regularly performing hand hygiene, observing respiratory hygiene and cough etiquette (“cover your cough”), and avoiding others and crowded areas when ill (social distancing) are important prevention methods for any contagious respiratory tract infection. Additional measures to limit transmission of influenza in health care settings are also essential. These include screening patients on arrival to assess for respiratory symptoms, placing a surgical mask on potentially infected individuals, using isolation precautions for those suspected of having or confirmed to have a respiratory tract infection, keeping infected patients away from other patients, and ensuring that visitors and health care personnel (HCP) do not visit or work while ill (i.e., “presenteeism”)…2.

FAQ Editor’s Note: This short article presents rebuttals to a series of “common arguments” including:
– “The vaccine does not work.”
– “The vaccine causes the flu.”
– “I have an allergy to eggs.”
– “I  cannot get the vaccine because I am pregnant or have an underlying medical condition or because I live with an immunocompromised person.”
– “I never get the flu/I am healthy.”


Influenza Vaccination Coverage Among Health-Care Personnel — 2011–12 Influenza Season, United States
The MMWR Weekly for Sept. 28, 2012 / Vol. 61 / No. 38
FAQ Editor’s Excerpt and Bolded Text
Influenza vaccination of health-care personnel (HCP) is recommended by the Advisory Committee on Immunization Practices (ACIP) (1). Vaccination of HCP can reduce morbidity and mortality from influenza and its potentially serious consequences among HCP, their family members, and their patients (1–3). To provide timely estimates of influenza vaccination coverage and related data among HCP for the 2011–12 influenza season, CDC conducted an Internet panel survey with 2,348 HCP during April 2–20, 2012. This report summarizes the results of that survey, which found that, overall, 66.9% of HCP reported having had an influenza vaccination for the 2011–12 season. By occupation, vaccination coverage was 85.6% among physicians, 77.9% among nurses, and 62.8% among all other HCP participating in the survey. Vaccination coverage was 76.9% among HCP working in hospitals, 67.7% among those in physician offices, and 52.4% among those in long-term care facilities (LTCFs). Among HCP working in hospitals that required influenza vaccination, coverage was 95.2%; among HCP in hospitals not requiring vaccination, coverage was 68.2%. Widespread implementation of comprehensive HCP influenza vaccination strategies is needed, particularly among those who are not physicians or nurses and who work in LTCFs, to increase HCP vaccination coverage and minimize the risk for medical-care–acquired influenza illnesses…

Influenza Vaccination Coverage Among Pregnant Women — 2011–12 Influenza Season, United States
Influenza A (H3N2) Variant Virus-Related Hospitalizations — Ohio, 2012
Postvaccination Serologic Testing Results for Infants Aged ≤24 Months Exposed to Hepatitis B Virus at Birth — United States, 2008–2011
Announcements: Final State-Level 2011–12 Influenza Vaccination Coverage Estimates Available Online
Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP)
This report updates the previously published summary of recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC) for vaccinating health-care personnel (HCP) in the United States. This report summarizes all current ACIP recommendations for vaccination of HCP and does not contain any new recommendations or policies. The recommendations provided in this report apply, but are not limited, to HCP in acute-care hospitals; long-term–care facilities (e.g., nursing homes and skilled nursing facilities); physician’s offices; rehabilitation centers; urgent care centers, and outpatient clinics as well as to persons who provide home healthcare and emergency medical services.
Nov. 25, 2011 / Vol. 60 / No. RR–7  – November 2011


FAQ Editor’s Note: We include this recent article because of its linkage to the unique role that HCP often play in providing direct care to potentially large numbers of patients in health care settings.

Policy Resistance Undermines Superspreader Vaccination Strategies for Influenza
Chad R. Wells, Eili Y. Klein, Chris T. Bauch
Research Article | published 07 Mar 2013 | PLOS Computational Biology 10.1371/journal.pcbi.1002945
Theoretical models of infection spread on networks predict that targeting vaccination at individuals with a very large number of contacts (superspreaders) can reduce infection incidence by a significant margin. These models generally assume that superspreaders will always agree to be vaccinated. Hence, they cannot capture unintended consequences such as policy resistance, where the behavioral response induced by a new vaccine policy tends to reduce the expected benefits of the policy. Here, we couple a model of influenza transmission on an empirically-based contact network with a psychologically structured model of influenza vaccinating behavior, where individual vaccinating decisions depend on social learning and past experiences of perceived infections, vaccine complications and vaccine failures. We find that policy resistance almost completely undermines the effectiveness of superspreader strategies: the most commonly explored approaches that target a randomly chosen neighbor of an individual, or that preferentially choose neighbors with many contacts, provide at best a relative improvement over their non-targeted counterpart as compared to when behavioral feedbacks are ignored. Increased vaccine coverage in super spreaders is offset by decreased coverage in non-superspreaders, and superspreaders also have a higher rate of perceived vaccine failures on account of being infected more often. Including incentives for vaccination provides modest improvements in outcomes. We conclude that the design of influenza vaccine strategies involving widespread incentive use and/or targeting of superspreaders should account for policy resistance, and mitigate it whenever possible.

Author Summary
Superspreaders are the small number of individuals responsible for the majority of infections. Theoretical models have shown how vaccinating superspreaders can be a highly efficient way to control disease. However, these models neglect behavior by assuming that superspreaders will always agree to be vaccinated. This is a problematic assumption for influenza vaccination, which is voluntary in most populations, and for which vaccine coverage is often suboptimal. We developed a model of seasonal influenza transmission on a network of individuals who make decisions about whether or not to get vaccinated based on known determinants of vaccine uptake, such as personal infection history, perceived vaccine risks, and social influences. We found that, because of feedbacks between disease spread and individual vaccinating behavior, attempts to boost vaccine coverage in superspreaders through the use of incentives or recruiting by social contacts are almost completely undermined by such feedbacks. For example, higher vaccine uptake in superspreaders reduces influenza incidence, which in the next season reduces the perceived need for vaccination among non-superspreaders, who then do not become vaccinated as much. Our results suggest that the design of potential strategies to reach influenza superspreaders should account for behavioral feedbacks, since they may blunt policy effectiveness.

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