Seasonal Influenza Vaccination and Health Care Workers (HCWs)

1
Seasonal Influenza Vaccination and Health Care
Workers (HCWs)

• 2015-2016 Influenza Season

Health Protection Surveillance Centre
National Immunisation Office
2
Protect yourselfProtect others
3
Format slide bank pick those slides that
suit your audience best

• Influenza
• Symptoms and burden in general and in HCWs
• Risk groups
• Vaccine uptake / HCWs in Ireland
• Reasons why HCWs decline
• Effectiveness in HCWs
• Safety of the vaccine
• Effectiveness in protecting patients
• Strategies to improve uptake
• Controversy in relation to influenza systematic
  reviews from Cochrane

4
Influenza (Flu)

• The flu is an infection that is caused by a flu
  virus. There are many different types of flu
  viruses.
• The flu affects the lungs, throat, nose, and
  other parts of the body.
• Unlike the common cold, the flu comes on
  suddenly, makes you very sick for a week or
  longer, and you may end up in hospital.

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In healthy adults symptoms of flu can range from
classic influenza to mild illness or asymptomatic
infection
Symptoms Cold Classic Flu
Fever Rare , except in very young children Usual ( 38oC 100.4 F) lasts 3-4 days, reduced in elderly
Headache Rare Prominent
General aches/ pains Slight Often severe
Fatigue/ Weakness Mild Sudden onset and can last up to 3 weeks
Extreme exhaustion Never Early and prominent
Stuffy nose Common Sometimes
Sneezing Usual Sometimes
Sore throat Common Sometimes
Cough, Chest discomfort Mild to moderate Common and can become severe
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Influenza complications

• Bacterial superinfections
• bacterial pneumonia
• croup
• respiratory disorders
• Decompensation of chronic diseases
• pulmonary disease
• heart disease
• renal insufficiency
• metabolic disease

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How Does the Flu Spread?

• Flu is spread through tiny droplets sprayed into
  the air when a sick person coughs, sneezes, or
  even talks.
• You can get sick from the droplets if they land
  in your nose, eyes, or mouth.
• You can also get the flu by touching a surface
  like a table or a doorknob that has the virus on
  it, then touching your mouth or nose.
• .

Courtesy CDC/ Brian Judd
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Who is most at risk of complications?

• Diseases
• Those with chronic medical conditions e.g.
  Chronic respiratory, cardiac etc., Diabetes
  Mellitus, neurological disorders,
  immunosuppressed either through disease or
  treatment including those with asplenia or
  splenic dysfunction, morbid obesity-BMI 40
• Vulnerable age
• Young children lt 5 years
• hospitalisation rates comparable to those aged
  50-64
• those under 6 months have highest hospitalisation
  rate of any age
• gt 65 years
• Account for 90 deaths from seasonal flu
• Pregnancy
• SAGE WHO background
  paper on Influenza vaccines and Immunization

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Flu is Dangerous

• When some people get the flu it may be mild, but
  for many others it could be fatal.
• Most of these excess deaths are in the
  elderly/those with underlying illness
• Death 0.5-1/1000 cases (1/10,000 pop per year).
• Approximately, 200-500 Irish people will die
  each year because of flu. In a bad year this can
  be up to 1000 people (2008-2009)
• Recent European study reported weeks of excess
  mortality coincided with medium or high influenza
  activity weeks
• Of the 411 people admitted to ICU in Ireland with
  lab confirmed flu since 2009
• 18 were healthy people with no underlying
  illness most were lt 65 years median age of
  those admitted to ICU ranged from 18 66 years
  depending on year Case fatality ratio varied,
  (range 18-36)

• K Mølbak et al. Excess mortality among the
  elderly in European countries, December 2014 to
  February 2015 (ttp//www.eurosurveillance.org/View
  Article.aspx?ArticleId21065
• HPSC ICU influenza surveillance

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Risk of Myocardial Infarction and Strokeafter
Acute Infection or Vaccination

• There was no increase in the risk of myocardial
  infarction or stroke in the period after
  influenza, tetanus, or pneumococcal vaccination.
• However, the risks of both events were
  substantially higher after a diagnosis of
  systemic respiratory tract infection (incidence
  ratio for myocardial infarction, 4.95 95 percent
  confidence interval, 4.43 to 5.53 incidence
  ratio for stroke, 3.19 95CI, 2.81 to 3.62).
• Smeeth L et al. Risk of Myocardial Infarction and
  Stroke after Acute Infection or Vaccination. N
  Engl J Med 2004 Dec 16351(25)2611-8

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Influenza vaccination inpatients with CHD

• Case control study of 218 patients with coronary
  heart disease (CHD) during the 199798 influenza
  season in the USA
• Efficacy of influenza vaccine in reducing the
  risk of recurrent myocardial infarction (MI) in
  patients with CHD

Vaccination associated with a reduced risk of
recurrent MI
Past and current influenza vaccination
reducesthe risk of recurrent MI in CHD patients
Naghavi M et al. Circulation 2000 102
303945.
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Risk of influenza-associated deaths

• Risk Risk to die within one year due to
• 1200 Smoking more than 10 cigarettes/day
• 15000 Influenza
• 18000 Street accident
• 112,000 Leukaemia
• 1500,000 Accident on railway
• 110,000,000 Lightning strike

Calman KC. BMJ. 1996313799-802.
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Everyone is at risk

• ?100 million people infected every year in
  Northern Hemisphere

110 adults
13 children
10,000-40,000 deaths in the USA
In North America, Europe, and Japan. ESWI.
Available at http//www.eswi.org/library/bulletins
/0499-4.html. CDC. MMWR. 200150(RR-04)1-46.
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Transmission of Influenza by HCW

• In a neonatal intensive care unit1
• 19/54 infants were infected and one died
• 15 of staff were vaccinated against influenza
• Only 29 of staff who reported influenza-like
  illness took time off work
• In an organ transplant unit attack rate 332
• Each patient was in an individual room and 3/4
  had no visitors to account for the spread
• 3/27 (11) HCWs on the ward had influenza not
  vaccinated
• In long-term facility3
• 65 residents developed influenza
• Over half developed pneumonia, 19 hospitalized, 2
  died
• 10 of HCW were vaccinated

Influenza infection can remain asymptomatic but
infectious4
1Cunney et al. Infect Control Hosp Epidemiol.
20002144951 2Malavaud S, et al.
Transplantation. 2001725357 3CDC. MMWR
19914129-131 4Elder G, et al. BMJ.
199631312412
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Characteristics of Influenza Hospitalisations in
Ireland over 6 influenza seasons
2014/2015 data provisional, further reported
cases expected.
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Characteristics of Influenza ICU admissions,
Ireland, over 6 influenza seasons
2014/2015 data provisional, further reported
cases expected.
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Summary influenza/ILI general outbreaks by
institution type 2014/2015 influenza season
Location No. of outbreaks Total number ill Total number hospitalised Total Number dead Total number lab confirmed
Comm. Hosp/Long-stay unit 26 355 39 2 80
Hospital 17 380 4 5 250
Residential institution 15 163 18 5 43
School 1 17 0 0 -
Total 59 915 61 12 373
Source CIDR
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Summary influenza/ILI general outbreaks in
institutional settings (all) by HSE area
2014/2015 flu season
HSE-area No. of outbreaks Total no. ill Total no. hospitalised Total no. dead Total no. lab confirmed Total no. lab investigated
East 17 407 1 6 240 64
Midlands 2 25 1 1 1 11
Midwest 6 69 24 3 27 25
Northeast 1 8
Northwest 11 116 5 1 30 42
Southeast 6 52 2 0 15 21
South 13 201 20 0 37 36
West 3 37 8 1 23 24
 Total 59 915 61 12 373 223
Source CIDR data
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ILI consultation rate, positive influenza A and B
specimens (NVRL), by week and year
(2012/13-2013/14)
Data for 2014-2015 not available at time of
presentation 1/10/2015
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But I dont get the flu
21
Actually

• One serosurvey showed 23 of HCW had serologic
  evidence of influenza virus infection during a
  single influenza season
• the majority had mild illness
  
  or subclinical
  infection

Elder G, et al. BMJ. 199631312412. Kuster SP
et al 2011. PLoS ONE 6(10)e26239.
doi10.1371/journal.pone.0026239
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How can you help?

• Stay home from work when you feel sick.
• Wash your hands or use hand sanitisers, sneeze
  in your sleeve or a tissue.
• But this is not enough
• People can still spread the flu even when they
  DONT feel sick.
• Up to 50 of infected people dont have symptoms
  when they are infected.
• People can spread flu germs before they feel
  sick.
• Flu is also spread through tiny droplets spread
  into the air when people cough or sneeze.
• The best protection is VACCINATION.

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Good News!!

• YOU can help protect your family, friends,
  patients, and yourself from the flu.

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Since Im Not at High Risk, Do I Need to Get the
Flu Vaccine?

• YES.
• When you get the flu it may be mild, but for
  those at high risk it could be fatal.
• Patients.
• Family Members and Friends.
• Getting the flu vaccine helps to protect the
  people you work so hard to keep healthy.

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Influenza Vaccine for all HCWs

• Recommended annually since 1999
• Increased risk of exposure
• Reduce staff illness and absenteeism
• Known to spread from workers to patients
• Vital to care of high risk patients
• Recent emphasis on influenza vaccine to ensure
  patient safety and as quality measure for
  organisations
• RCPI National Immunisation Guidelines for
  Ireland. (editions 1999/2202/2008/2013)
• HCWs all staff (including ancillary staff, such
  as cleaners, porters, kitchen staff) working in
  health care setting or health related activities
  in acute and non acute health care settings,
  including those working in health related
  activities in the community settings

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The vaccine

• This years (2014-2015) seasonal flu vaccine
  contains 3 strains of flu viruses as recommended
  by the World Health Organization (WHO) as the
  strains most likely to be circulating this
  season. The three strains are
• Influenza A/California/7/2009 (H1N1)pdm09-like
  virus
• Influenza A/Switzerland/9715293/2013 (H3N2)-like
  virus
• Influenza B/Phuket/3073/2013-like virus
• This vaccine is an inactivated split virion
  vaccine, does not contain any adjuvant.
• It does not contain thiomerosal.

• Is there anyone who cannot get flu vaccine?
• Most people can get flu vaccine.
• It is not recommended for those who have
• a history of anaphylaxis following a previous
  dose of flu vaccine or any part of the vaccine. 
• What about people with egg allergy?
• People with egg allergy can get seasonal flu
  vaccine. This may be given by your occupational
  health unit or GP or you may need referral to a
  hospital specialist. See RCPI NIAC guidelines

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Influenza vaccines- two types available

• Inactivated trivalent vaccine
• contains antigens from two type A and one type B
  virus strains cultured in eggs or in cell lines
• whole virus, split-virus (subvirion), and
  surface-antigen vaccines are of equivalent
  efficacy but the latter two are less likely to
  induce febrile reactions in children.
• supplied in a prefilled syringe for IM injection.
• 2. Live attenuated influenza quadrivalent vaccine
  (LAIV)
• contains antigens from two type A and two type B
  virus strains cultured in eggs.
• vaccine is administered intranasally

Source NIAC guidance updated August 2015.
http//www.hse.ie/eng/health/immunisation/hcpinfo/
guidelines/chapter11.pdf
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Administration of vaccines

• Inactivated vaccine
• dose is 0.5ml given by intramuscular injection
  into the anterolateral thigh or deltoid.
• Live attenuated influenza vaccine (LAIV)
• dose is 0.2ml given by nasal spray 0.1 ml into
  each nostril
• LAIV immunisation must be given intranasally.
• Children lt 9 years of age and those who are
  immunosuppressed require two doses of vaccine,
  separated by 4 weeks if receiving the vaccine for
  the first time.
• Not routinely available from HSE

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European Council Recommendation on seasonal
influenza vaccination 22 December 2009

• Member States are recommended
• To achieve vaccination coverage in older age
  groups and risk groups of individuals suffering
  from chronic diseases and conditions
• Recommended Target 75 by the winter season of
  2014/2015
• To mitigate the impact of seasonal influenza
  among health care workers
• For 2014/2015 Ireland (provisional data
  PCRS/HPSC)
• Uptake among elderly gt 65 years of age
  (medical/GP only card holders) was 63 (source
  PCRS)

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HCW and vaccination Why are we concerned?

• HCWs frequently implicated as the source of
  influenza transmission in health care settings
• Employees continue to work while sick with
  influenza
• Unvaccinated workers who are not sick can still
  spread the virus
• Benefits of influenza vaccination of HCWs
• Reduce risk of outbreaks in health care
  facilities
• Decrease staff illness and absenteeism
• Reduce costs resulting from loss of productivity

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Yet still HCW vaccination rates remain low
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VENICE studySeasonal influenza vaccination
uptake among HCWs in 15 EU/EEA Member States,
2008/09-2012/13
Health care workers in GPs practice Source
VENICE survey http//venice.cineca.org/
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Uptake by Hospital Staff Category by Season
Results based on complete returns consisting of
eligible and vaccinated staff numbers by HSE
grade in 21 hospitals that reported back in each
survey over the past four seasons
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Uptake by LTCF Staff Category by Season
Results based on complete returns consisting of
eligible and vaccinated staff numbers by HSE
grade in 21 LTCFs that reported back in each
survey over the past four seasons
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Reasons for not taking vaccination advanced by
health care workers
The flu vaccine can give me the flu
I never get the flu and I dont feel I need the
vaccine
Since I am around sick people all the time, I am
already immune to the flu
I am a healthy person and would prefer my immune
system to protect me against the flu
I am worried about having an adverse reaction to
the vaccine
I dont believe in it
The vaccine doesnt work on me. I got the flu
anyway
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Reasons for not getting influenza vaccine among
Irish HCWs (n 92), 2006
Mereckiene J et al. Euro Surveill. 200712(12).
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Does the Flu Vaccine Work?

• YES!
• Systematic reviews have shown that flu vaccine
  has reduced the flu incidence rate from 18.7 in
  unvaccinated HCWs to 6.5 in vaccinated HCWs
• Kuster SP et al. Incidence of Influenza in Health
  adults and Health Care Workers A systematic
  review and Meta Analysis 2011 PLoS ONE
  6(10)e26239. doi10.1371/journal.pone.0026239
• .

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Factors influencing vaccine efficacy

• Closeness of the match between the vaccine strain
  and the circulating virus
• Age of vaccinee
• older people do not respond as well
• Health of the vaccinee
• people with chronic illnesses and immune system
  disorders do not respond as well as healthy
  individuals
• Number of vaccinations
• in children under 9 two doses are required in the
  first year of use
• Type of vaccine used
• adjuvanted vaccines can give better immune
  response

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Effectiveness of inactivated influenza vaccine in
adults

• Effectiveness dependent on match with circulating
  virus
• Seasonal
• Vaccine closely matched to circulating strain
• 73 effective in healthy adults lt65 years of age
  against influenza symptoms, whereas 44 when not
  well matched
• Jefferson T et al Vaccines for preventing
  influenza in healthy adults Cochrane Database
  Syst Rev 2010CD001269
• Pooled efficacy results of 59 in adults aged
  18-65
• Osterholm MT, Kelley NS, Sommer A, Belongia EA.
  Efficacy and effectiveness of influenza vaccines
  a systematic review and meta-analysis. Lancet
  Infect Dis. Jan 201212(1)36-44.

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Is Flu Vaccine Safe?

• YES! The flu vaccine is very safe. The benefits
  far outweigh any possible side effects.
• Some people may have redness and soreness where
  they received the vaccine
• Serious side effects are rare.
• Guillain Barré recent studies show reduced after
  vaccine but increased after influenza
• Narcolepsy has not been linked to seasonal flu
  vaccine

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Does flu vaccine give you the flu?- NO

• It cannot cause flu
• influenza viruses in vaccine currently used in
  Ireland are inactivated (killed) during
  manufacturing process
• cannot cause infection
• batches of vaccine are tested to ensure safety
• Randomised placebo (saline , vaccine diluent)
  controlled studies have demonstrated safety
• only differences in symptoms between vaccinated
  and non-vaccinated was increased soreness in the
  arm and redness at the injection site
• no differences in terms of body aches, fever,
  cough, runny nose or sore throat.

Carolyn Bridges et al. (2000). JAMA.
284(13)16551663. Kristin Nichol et al.
(1995). NEJM. 333(14) 889-893.
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Vaccine side-effects

• Most common side effect of seasonal flu vaccine
• soreness at injection site, usually lt 2 days
• Rare symptoms
• fever, muscle pain, and feelings of discomfort or
  weakness
• usually begin soon after vaccination and last 1-2
  days
• Frequency
• local reactions 15-20 recipients
• Fever, malaise not common, resolve
• Allergic reactions rare
• Neurological reactions very rare

43
Debunking the Myths I got sicker from the
vaccine than when I actually got the fluN Engl
J Med 20013451529-36.)
SYMPTOMS VACCINE PLACEBO
Rhinitis 44.8 45
Sore throat 28.3 28.7
Cough 46.1 45.7
Headache 39.6 37.8
Myalgia 25.1 20.8
Chills 12.2 11.1
Fever 5.1 5.0
Fatigue 27.9 28.6
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What is Guillain-Barré Syndrome (GBS)?

• a rare neurological disease that causes
  temporary weakness or paralysis of the muscles
• Frequently preceded by a viral or bacterial
  illness (campylobacter)
• In the literature
• 1976 influenza vaccine associated with increased
  risk vaccine was discontinued
• Since then no clear association between GBS and
  influenza vaccines
• If risk exists, estimated at 1 - 2 cases per
  million people vaccinated
• Risk of GBS after vaccination is lower than the
  risk of GBS after influenza

Stowe J et al. Am J Epidemiol 2009169382-8
45
If I get vaccinated, will it really make a
difference to my patients?
46
Does Vaccinating Health Care Workers (HCWs)
Really Help?
YES !

Many studies have shown that increasing the
vaccination rates of HCWs decreases patient
illness and death. One study showed a 40
reduction of influenza related deaths in
hospitals with higher rates of HCP influenza
vaccination.
Carman WF GD, et al. Lancet 2000355937.
47
Vaccination of HCW reducesnosocomial influenza
cases

• Monitored for 12 years (87-99)
• Coverage rate increased from 4 to 67
• Lab confirmed cases-staff
• Dropped from 42 (1990-93) to 9 (1997-2000)
• Nosocomial cases among hospitalized patients
• Decreased 32 to 0 (plt0.0001)

Salgado et al. Infect Control Hosp Epidemiol
200425923-928
48
Patient outcomes

• Most reported trials in nursing homes
• Studies of staff vaccination have shown decrease
  mortality of residents 1, 2
• One cluster randomised clinical trial3 with 44
  nursing homes residents
• When staff offered vaccine (48 coverage) vs. not
  offered (6 coverage), impact on residents
• Decrease mortality
• Decrease in ILI
• Decrease in medical visits for ILI

1. Carman WF, et al. Lancet 200035593--7. 2.
Potter J, et al. J Infect Dis 19971751--6. 3.
Hayward AC, et al.BMJ 20063331241.
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Vaccinating HCWs and impact on patient mortality
Increased vaccination rates of HCWs working in
long-term care geriatric hospitals have been
associated with a reduction in patient mortality
20 long-term care geriatric hospitals in Scotland
randomised and followed for 6 months during the
199697 season (1217 HCWs, 1437 patients)
HCWs in 10 hospitals not offered vaccination
HCWs in 10 hospitals offered vaccination
HCWs in 10 hospitals not offered vaccination
HCWs in 10 hospitals offered vaccination
5 of HCWs vaccinated
50 of HCWs vaccinated
5 of HCWs vaccinated
50 of HCWs vaccinated
688 patients monitored
749 patients monitored
749 patients monitored
Crude patient mortality 22
Crude patient mortality 14
Crude patient mortality 14
Carman WF, et al. Lancet. 2000355937.
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Benefits of Influenza Vaccination in Health Care
Workers

• 1) protects HCW against influenza
• 2) provides indirect protection against influenza
  to the high-risk patients
• 3) reduces absenteeism from work
• 4) is cost-effective and probably cost-saving

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Does getting vaccinated really keep the workforce
more healthy?
52
Absenteeism of HCW

• Double blind, randomised, placebo controlled
  trial
• 2 large teaching hospitals over 3 years
• Vaccinated vs. controls
• Vaccinated group with lower incidence of
  influenza (1.7) compared to controls (13.4)
• Estimated vaccine efficacy against serologically
  defined influenza A and influenza B infection of
  88 and 89
• Trend toward
• fewer total respiratory illnesses (28.7 per 100
  persons) vs. controls (40.6 per 100 persons)
• Fewer days of lost work (9.9 per 100 persons) vs.
  21.1 per 100 persons for controls

Wilde JA, McMillan JA, Serwint J, Butta J,
O'Riordan MA, Steinhoff MC. Effectiveness of
influenza vaccine in health care professionals a
randomized trial. JAMA 1999281908--13.
53
Vaccination and reduction of HCW absenteeism
427 HCWs in two Finnish paediatric hospitals
randomized to influenza vaccine or placebo and
followed (double blind) for 4 months during
199697 season
216 vaccinated against influenza
211 received placebo
301 days sick leave due to respiratory infections
218 days sick leave due to respiratory infections

• Vaccination was associated with a 28 decrease (p
  0.02) in absenteeism related to respiratory
  infections
• No effect on the total number of days with
  respiratory infections (with or without sick
  leave) nor on antibiotic use

Saxen H, et al. Pediatr Infect Dis J.
19991877983.
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What the vaccine does/does not do

• Does
• protect against influenza from 2 weeks after
  vaccination up to a year later
• Decreases risk of influenza disease and
  complications
• Hospitalisation and severe illness incl. Guillain
  Barre after influenza-like illness
• Does not
• Prevent influenza-like illnesses caused by
  other viruses
• Increase risk of Guillain Barré syndrome after
  vaccination

Stowe J et al. Am J Epidemiol. 2009 Feb
1169(3)382-8.
55
Cost-effectiveness for healthy adults

• Healthy adults (lt65 years of age) savings
  include
• 13-44 fewer health-care provider visits
• 18-45 fewer lost workdays
• 18-28 fewer days working with reduced
  effectiveness
• 25 decrease in antibiotic use for ILI
• Savings categories
• Reduction in direct medical costs
• Decreased indirect costs from lost work
  productivity
• gt70 of cost savings

Molinari NA, Ortega-Sanchez IR, Messonnier ML,
et al. The annual impact of seasonal influenza in
the US measuring disease burden and costs.
Vaccine 2007255086--96.
56
Influenza in HCWs has a substantial economic
impact on healthcare structures

• University Hospital of Zurich, 19992000 season
• 200 employees
• 4.3 days off work per employee presenting with an
  influenza-like illness
• 29.5 attack rate
• Overall economic impact on the hospital
  (including 5,525 employees)
• Cost of lost productivity for influenza
  represented 0.050.1 of overall personnel
  expenditure

Productivity loss (days) Annual personnel expenditure (US)
Influenza-like illness 3,0969,079 0.421.2 million
Laboratory-confirmed influenza 6461,943 102,500300,000
Szucs TD, et al. Infect Control Hosp Epidemiol.
2001224724.
57
Strategies to increase uptake

1. Organised vaccination programmmes
2. Emphasis on Duty-of-Care
3. Education and debunking the myths
4. Support from senior staff
5. Mandatory vaccination/declination
6. Provision of free, easily accessible vaccines in
   a convenient matter

58
Rates with Different Interventions
Factor Vaccination rate in Programmes with Vaccination rate in Programmmes without
Weekend provision of vaccine 58.8 43.9
Train-the-trainer programs 59.5 46.5
Report of vaccination rates to administrators 57.2 48.1
Letter sent to employees emphasizing the importance of vaccination 59.3 47
Any form of visible leadership support 57.9 36.9
Required declination 56.9 55
Talbot TR. Dellit TH. Hebden J. Sama D. Cuny J.
Factors associated with increased healthcare
worker influenza vaccination rates results from
a national survey of university hospitals and
medical centers. Infect Control Hosp Epidemiol.
31(5)456-62, 2010 May
59
If You Dont Get the Flu

• You wont need to take time off from work because
  you are sick with the flu.
• HCWs who receive flu vaccine take about 50 fewer
  sick days.
• You wont need to pay for doctor visits and
  medication to treat the flu.
• Immunised HCWs have about 44 fewer doctor
  visits.
• You wont need to cancel activities with friends
  and family because you are sick with the flu.
• Immunized HCWs have a 59 reduction in illness
  during vacation time.

Wilde JA, et al . Effectiveness of influenza
vaccine in health care professionals a
randomized trial. JAMA 1999281908--13.
Nichol KL, M, et al. The effectiveness of
vaccination against influenza in healthy, working
adults. N Engl J Med 199533388993..
Influenza Vaccination of Health-Care Personnel
Recommendations of ACIP and HICPAC-MMWR 2006
60
Since Ive Been in the Health Care Field for a
Long Time, am I Already Protected Against the
Flu?

• No, this is not possible.
• Flu virus changes every year.
• Your body cannot protect itself from new types of
  flu because your immune system does not recognise
  it.
• A different vaccine is needed every year.
• You need to get a flu vaccine every year.

61
Why Get Vaccinated Against the Flu?

• Protect yourself.
• Protect your patients.
• Protect your family and friends.
• Flu vaccination
• is FREE.
• is safe.
• is quick and easy.
• can save you time and money.
• Vaccination is the BEST protection
• you have against the flu!

62
Why annual vaccination?

• Influenza viruses always changing.
• Strains monitored by WHO surveillance
  laboratories
• WHO recommends strains for inclusion in seasonal
  flu vaccine every year
• Seasonal flu vaccine formulated to match
  circulating strains

63
2 Recent conflicting systematic reviews

• Thomas RE et al reported on 3 randomised
  controlled trials and found no reasonable
  evidence that vaccination of HCWs protected
  residents in LTCF. They did not look at all cause
  deaths and restricted outcomes to lab confirmed
  influenza or hospitalisation or death due to a
  lower respiratory tract illness
• Ahmed et al from CDC identified four
  cluster-randomised trials and four observational
  studies conducted in long-term care or hospital
  settings. They estimated that all cause death was
  reduced by 29 and ILI by 42.
• Thomas RE et al. Influenza vaccination for
  healthcare workers who care for people aged 60 or
  older living in long-term care institutions.
  Cochrane Database Syst Rev.20137CD005187
• Faruque Ahmed et al. Effect of Influenza
  Vaccination of Health Care Personnel on Morbidity
  and Mortality among Patients Systematic Review
  and Grading of Evidence Clinical Infectious
  Diseases Advance Access published September 17,
  2013

64
Accompanying Editorial in CID Marie Griffin
September 2013

• Sir Austin Bradford Hill
• All scientific work is incompletewhether it be
  observational or experimental. All scientific
  work is liable to be upset or modified by
  advancing knowledge. That does not confer upon us
  a freedom to ignore the knowledge we already
  have, or postpone the action that it appears to
  demand at a given time.
• The meta-analysis by Ahmed et al. offers
  additional reassurance that the threshold for
  action has been reached or surpassed. Vaccination
  of healthcare workers to protect vulnerable
  patients and residents of long term facilities
  should be viewed as an evidence-based
  recommendation

65
HCW and vaccination Where are we in Ireland?

• Poor uptake of immunisation among Irish HCWs
• Historically poor but improving
• Inter-hospital/facility variation
• High risk of transmission in health care setting
  to vulnerable groups
• High risk of complications in risk groups
• Human and economic impact of influenza
• employee absenteeism, disease among patients,
  burden on health services
• Poor knowledge
• Low perception of self risk or risk to others
  among HCWs
• Myths and inaccurate information common

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What can be done to improve the situation?

• Develop strong position on HCWs influenza
  immunisation
• leadership and department/institution support
• Aim high (uptake gt 40)
• Highlight benefits of HCW immunisation
• Personal/ patient /family
• Decreased transmission among staff and patients
  deaths/complications/prolonged hospital stays/
  absenteeism
• Educate early and often and avoid confusion among
  HCWs
• dangers of influenza transmission from HCWs to
  patients, patient care responsibility
• Highlight vaccine safety and efficacy- and years
  of safe usage
• Dispel myths You cannot get influenza from the
  injectable vaccine, side effects minimum
• Communication tools
• posters, leaflets, newsletter articles, e-mails,
  text messaging

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Improve Influenza Immunisation

• Make it attractive
• Convenient and comfortable (site and time)
• Incentives and rewards (raffles, spot prizes,
  chocolates)
• Inter-departmental/team competition uptake by
  units published
• Identify key person on each unit/ward/team
• responsible for encouraging vaccination,
  vaccinating
• Make it accessible
• Multiple opportunities (during day/night, week,
  month)
• Continuous programme October-March
• Avoid missed opportunities
• offer immunisation during any contact
• Bring vaccine to staff
• mobile teams, multiple sites, target group
  gatherings, team meetings
• Throughout work day (and night)

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Monitoring and evaluation

• Monitor
• Uptake by units and professional group
• Health care-associated illness during season
• Evaluate
• Differences between groups and units
  investigate reasons for differences
• Report and share information
• Demonstrate high performing areas
• Introduce competition
• Demonstrate safety and uptake
• Information may stimulate HCWs to seek
  vaccination

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Protect your patients, your self, colleagues,
family and friends
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More information on influenza 2015-2016 season

• HPSC
• http//www.hpsc.ie/A-Z/Respiratory/Influenza/Seaso
  nalInfluenza/
• National immunisation Office
• http//www.immunisation.ie/en/HotTopics/Text_17465
  _en.html